Ultrasound-guided fascial plane blocks for post-breast surgery pain syndrome.

INTRODUCTION: Persistent pain following breast surgery is common and may be challenging to treat. In patients refractory to conservative treatments, ultrasound-guided fascial plane blocks of thoracic nerves can be a useful option. RESULTS: This type of neuro blockade technique provides advantages in terms of safety and efficacy that are convenient for physicians managing refractory and complex cases of post-breast surgery syndrome. CONCLUSION: This technical review aims to present an up-to-date summary of the most common ultrasound-guided fascial plane blocks for chronic pain in post-breast surgery patients, provide a detailed technical description of each intervention, and propose preferred injections based on the anatomical location of the pain.

A retrospective case series of prophylactic neurectomy during total knee arthroplasty.

INTRODUCTION: Total knee arthroplasty is a common operation performed to relieve pain and restore functional activity. While overall widely successful, a subset of patients has continued pain postoperatively with no identifiable cause. Neuroma formation has been identified as a possible contributor to this unexplained pain, often necessitating an additional procedure for neuroma removal. The purpose of our study was to evaluate if prophylactic neurectomy could reduce the occurrence of postoperative pain. METHODS: A total of 112 patients were compared, 44 control patients and 68 neurectomy patients. Demographic information, Numerical rating pain scale (NRS) and Knee Society Scores (KSS) were collected pre- and post-operatively. Patients were additional asked if they were overall satisfied with the operation. RESULTS: There were no differences between groups with respect to age (Median: 71 vs 69 years, p = 0.28), male sex (41% vs 44%, p = 0.85), or body mass index (Median: 32.2 vs 31.3, p = 0.80). When comparing the degree of change following surgery there were no statistically significant differences observed in NRS pain scores (Median change: -7 vs -6, p = 0.89) or KSS scores (Median change: +44 vs +40, p = 0.14). Similarly, there was no statistically significant difference in overall patient-reported satisfaction with the knee replacement (82.5% vs 86.6%, p = 0.59). CONCLUSION: We did not find a statistically significant difference in NRS, KSS, or overall patient satisfaction between the prophylactic neurectomy and control patient groups. Larger studies with evaluation of the nerve diameter will be needed to determine which patients are at risk for symptomatic neuroma development following total knee arthroplasty.

Intraoperative Epicardial Ultra-High Frequency Ultrasound in Coronary Artery Bypass Grafting Surgery.

The use of intraoperative epicardial ultrasound in order to aid physicians and surgeons in open cardiac surgery has been established for quite some time. Recently, the development of ultra-high frequency ultrasound (UFHUS), 50-70 megahertz (MHz) technology has resulted in high-resolution imaging capabilities previously unavailable for clinical use. This report is the first to describe the use of intraoperative UFHUS epicoronary scanning to assess coronary anatomy and visualize cardioplegia flow within native coronary vessels.

Application of Color Doppler Ultrasound to Identify and Repair Postoperative Cerebrospinal Fluid Leak: A Technical Note.

BACKGROUND: Incidental durotomy is a known complication of spinal surgery. Persistent cerebrospinal fluid (CSF) leak after unrecognized durotomy may lead to prolonged hospitalization and significant morbidity. If initial bed rest fails, the surgeon must choose between nontargeted methods such as oversewing the wound and lumbar drain placement or return to the operating room. OBJECTIVE: To report the novel use of color flow doppler (CFD) in conjunction with ultrasound (US) to localize the point of CSF leak, assist with aspiration of the pseudomeningocele, and direct the application of fibrin sealant or epidural blood patch. METHODS: This article includes a description of the technique as a technical note. RESULTS: A 72-year-old man underwent L2-5 laminectomies for spinal stenosis. During the index operation, a durotomy occurred and was repaired primarily. The patient subsequently developed leg weakness, back pain, and bulging of the incision. Using CFD, the site of durotomy was determined. Under direct visualization, 34 mL of CSF was aspirated from the pseudomeningocele and 20 mL of fibrin sealant was placed opposing the durotomy. At 2-month follow-up, CFD confirmed absent flow and MRI demonstrated pseudomeningocele resolution. CONCLUSION: This article represents the first report highlighting the utility of CFD US to guide epidural patch placement for postsurgical CSF leaks. CFD allows localization of the durotomy and direct application of blood or fibrin sealant, potentially increasing the success rate of epidural blood patch in postoperative patients. This approach is less invasive than revision surgery and does not require the prolonged hospitalization of lumbar drainage or other nontargeted interventions.

Initial Results of Precision Treatment of Postoperative Cerebrospinal Fluid Leak with Ultrasound-Guided Epidural Blood Patch.

BACKGROUND: Incidental durotomy, a known complication of spinal surgery, can lead to persistent cerebrospinal fluid leak and pseudomeningocele if unrecognized or incompletely repaired. We describe the use of ultrasound to visualize the site of durotomy, observe the aspiration of the pseudomeningocele, and guide the precise application of an ultrasound-guided epidural blood patch (US-EBP), under direct visualization in real time. METHODS: A retrospective review was performed to determine demographic, procedural, and outcome characteristics for patients who underwent US-EBP for symptomatic postoperative pseudomeningocele. RESULTS: Overall, 48 patients who underwent 49 unique episodes of care were included. The average age and body mass index were 60.5 (±12.6) years and 27.8 (±4.50) kg/m2, respectively. The most frequent index operation was laminectomy (24.5%), and 36.7% of surgeries were revision operations. Durotomy was intended or recognized in 73.4% of cases, and the median time from surgery to symptom development was 7 (interquartile range 4-16) days. A total of 61 US-EBPs were performed, with 51.0% of patients experiencing resolution of their symptoms after the first US-EBP. An additional 20.4% were successful with multiple US-EBP attempts. Complications occurred in 14.3% of cases, and the median clinical follow-up was 4.3 (interquartile range 2.4-14.5) months. CONCLUSIONS: This manuscript represents the largest series in the literature describing US-EBP for the treatment of postoperative pseudomeningocele. The success rate suggests that routine utilization of US-guided EBP may allow for targeted treatment of pseudomeningoceles, without the prolonged hospitalization associated with lumbar drains or the risks of general anesthesia and impaired wound healing associated with surgical revision.

Ultrasound-Guided Percutaneous Peripheral Nerve Stimulation for the Treatment of Chronic Intractable Pain Originating From a Lipofibromatous Hamartoma of the Median Nerve.

This case report presents an application of peripheral nerve stimulation to the median nerve to treat a patient with intractable pain due to a lipofibromatous hamartoma of the left upper extremity. Ultra high-frequency ultrasound was used to determine the boundaries of the hamartoma. The patient then underwent an ultrasound-guided implantation of 2 stimulator electrodes distal to the elbow along the median nerve with stimulation coverage achieved at 1.2 and 1.4 mA, respectively. After an uneventful procedure, the pain score immediately decreased from 9 out of 10 to less than 6 on a numeric rating scale. Two weeks after the procedure, the patient reported substantial pain relief, with an average pain level of 5 to 6 out of 10. Twelve months after implantation, the patient maintained significant pain relief, rating her average pain level as a 4 to 6 out of 10. Placement of a percutaneous peripheral nerve stimulator was safe and effective with no adverse events being reported at the 12-month follow-up.

A Comparative Study of Automated Pulsed Bolus versus Continuous Basal Infusion on Distribution of Contrast in the Transversus Abdominis Fascial Plane in a Cadaver: A Technical Report.

Integrating regional anesthesia and multi-modal pain management is a well described and successful strategy to reduce post-operative pain. The use of transversus abdominis plane (TAP) blocks has been well-described for abdominal surgery, which includes various injection sites to improve analgesic coverage and catheter usage to prolong duration of analgesia. After a cadaver contrast study, our investigation illustrates that, for a TAP catheter block, a programmed intermittent bolus provides greater spread of the injection in the fascial plane as compared to a continuous infusion. Clinical trials are needed to investigate if these findings translate to greater analgesic coverage of the anterior abdominal wall, particularly in the subcostal region.

Use of Ultra-high-frequency Ultrasound on Diagnosis and Management of Lipofibromatous Hamartoma: A Technical Report.

Lipofibromatous hamartoma (LFH) is a rare, benign tumor found in the peripheral nerves which is challenging to diagnose. We present a case report of the use of ultra-high-frequency ultrasound (UHFUS) on a patient with an LFH to provide valuable information not available on other imaging modalities regarding tumor invasion of the nerve fascicles.

A Comparative Study of Automated Pulsed Bolus Versus Continuous Basal Infusion on Distribution of Dye in the Paravertebral Space in a Cadaver.

Adequate pain control following thoracic surgery is important to enhance post-operative recovery. Paravertebral catheters have been reported to have a variety of clinical applications, including the blunting of surgical pain, lessening the need for opioids, and improvement in post-operative ventilation. The spread of local anesthesia to multiple paravertebral spaces is needed to establish an effective block. We have determined that the spread of contrast dye by a catheter in the thoracic paravertebral space is greater in a programmed intermittent bolus than in a continuous basal infusion.

Ultra-high-frequency Ultrasound to Assess Nerve Fascicles in Median Nerve Traumatic Neuroma.

A traumatic neuroma is a major cause of persistent neuropathic pain. Diagnostic imaging tools are critical to the success of surgical treatment. Ultra-high-frequency ultrasound is a novel technology that can generate frequencies up to 70 MHz, assessing structures up to 30 µm. We report a unique case of intraoperative use of ultra-high-frequency ultrasound to provide detailed imaging of nerve fascicles, facilitating surgical excision of the mass.

Early In-Hospital Pain Control Is a Stronger Predictor for Patients Requiring a Refill of Narcotic Pain Medication Compared to the Amount of Narcotics Given at Discharge.

BACKGROUND: The United States is combating an opioid epidemic. Orthopedic surgeons are the third highest opioid prescribers and therefore have an opportunity and obligation to assist in the efforts to reduce opioid use and abuse. In this article, we evaluate risk factors for patients requiring an opioid refill after primary total knee arthroplasty, with the goal to reduce opioid prescriptions for those patients at low risk of requiring a refill in order to reduce the amount of unused medication. METHODS: We retrospectively reviewed narcotic-naïve patients who underwent total knee arthroplasty from December 2017 to May 2018. We performed multivariable analysis on demographics and preoperative, operative, and postoperative characteristics to determine risk factors for requiring a prescription refill following hospital discharge. RESULTS: One-hundred fifty-seven patients were included in the analysis. Sixty percent of patients required a prescription refill. Risk factors included younger age (P = .003) and increased pain on postoperative day one (P < .001). The amount of narcotic medication given at discharge did not independently affect the refill rate (P = .21). CONCLUSION: There is strong evidence that elderly patients and those with good pain control on postoperative day 1 are at a lower risk of requiring a narcotic refill postoperatively. With this information, physicians may begin to tailor narcotic prescriptions based on patient risk factors for requiring a prescription refill rather than provide patients with the same number of pills for a given surgery in an effort to reduce unused narcotic medication.

Intraoperative evaluation of cervical nerve root avulsion using ultra-high-frequency ultrasound system.

Avulsion of C5 and C7 nerve roots was confirmed intraoperatively in a 21 year old male presenting after motor vehicle accident with confirmed absence of somatosensory evoked potentials upon stimulation via ultra-high-frequency ultrasound (70 MHz). Ultra-high-frequency ultrasound can be used as a reliable tool to directly visualise nerve injury.

Challenges of Managing Patients with Symptomatic Large Traumatic Cervical Pseudomeningoceles.

BACKGROUND: Traumatic cervical pseudomeningoceles (TCPs) occur secondary to traction of the cervical nerve roots resulting in violation of the dura. Surgical repair is not necessary in most cases because pseudomeningoceles have a high propensity to spontaneously resolve with conservative management alone. Currently, there are a limited number of cases of large TCPs (large is defined as ≥6 cm in greatest diameter), and there is no established guideline for the management of such lesions. CASE DESCRIPTION: We describe the cases of 2 young men in their 20s who were involved in a motor vehicle accident. Both patients suffered a brachial plexus injury and developed large TCPs. Patient 1 was treated surgically for TCP using a combined intra-/extradural approach using a fascia lata graft. Patient 2 was ultimately treated nonsurgically because a spontaneous resolution of the pseudomeningocele was achieved over the period of 7 months after the accident. Both patients underwent brachial plexus repair surgery consisting of spinal accessory nerve transfer to the suprascapular nerve and intercostal nerve transfer to the musculocutaneous nerve. CONCLUSIONS: Disease progression of TCPs is a dynamic process, and even large lesions may spontaneously resolve without surgical intervention. When surgery is indicated, a definitive dural repair using a fascia lata graft to cover the dural tear intra- and extradurally is an effective method. Surgery must be planned carefully on a case-by-case basis, and close follow-up with thorough physical examination and serial imaging is critical to monitor disease progression.

Whole-exome sequencing of a family with local anesthetic resistance.

BACKGROUND: Local anesthetics (LA) work by blocking sodium conductance through voltage-gated sodium channels. Complete local anesthetic resistance is infrequent, and the cause is unknown. Genetic variation in sodium channels is a potential mechanism for local anesthetic resistance. A patient with a history of inadequate loss of sensation following LA administration underwent an ultrasound-guided brachial plexus nerve block with a complete failure of the block. We hypothesized that LA resistance is due to a variant form of voltage-gated sodium channel. METHODS: Whole-Exome Sequencing. The patient and her immediate family provided consent for exome sequencing, and they were screened with a questionnaire to identify family members with a history of LA resistance. Exome sequencing results for four individuals were referenced to the 1000 Genomes Project and the NHLBI ESP to identify variants associated with local anesthetic resistance present in less than 1% of the general population and located in functional regions of the genome. RESULTS: Exome sequencing of the four family members identified one genetic variant in the voltage-gated sodium channel shared by the three individuals with LA resistance but not present in the unaffected family member. Specifically, we noted the A572D mutation in the SCN5A gene encoding for Nav1.5. CONCLUSIONS: We identified a genetic variant that is associated with LA resistance in the gene encoding for Nav1.5. We also demonstrate that Nav1.5 is present in human peripheral nerves to support the plausibility that an abnormal form of the Nav1.5 protein could be responsible for the observed local anesthetic resistance.

Ultrasound-guided transversus abdominis plane blocks for patients undergoing laparoscopic hand-assisted nephrectomy: a randomized, placebo-controlled trial.

Postoperative pain is a common complaint following living kidney donation or tumor resection using the laparoscopic hand-assisted technique. To evaluate the potential analgesic benefit of transversus abdominis plane blocks, we conducted a randomized, double-blind, placebo-controlled study in 21 patients scheduled to undergo elective living-donor nephrectomy or single-sided nephrectomy for tumor. Patients were randomized to receive either 20 mL of 0.5% ropivacaine or 20 mL of 0.9% saline bilaterally to the transversus abdominis plane under ultrasound guidance. We found that transversus abdominis plane blocks reduced overall pain scores at 24 hours, with a trend toward decreased total morphine consumption. Nausea, vomiting, sedation, and time to discharge were not significantly different between the two study groups.

Breast cancer recurrence in patients receiving epidural and paravertebral anesthesia: a retrospective, case-control study.

PURPOSE: Studies have suggested an association between the use of regional paravertebral or epidural anesthesia and a reduction in tumor recurrence following breast cancer surgery. To examine this relationship we performed a retrospective case-control study of patients undergoing breast cancer surgery receiving regional, regional and general, or general anesthesia. METHODS: A retrospective chart review was performed of patients undergoing surgery for stage 0 to III breast cancer. Patients identified as receiving regional anesthesia were then matched for age, stage, estrogen receptor (ER) status, progesterone receptor status, and HER-2 expression with patients who received no regional anesthesia. Univariate (Pearson's χ2 test and odds ratio) and multivariate logistic analyses with backward stepwise regression were performed to determine factors associated with cancer recurrence. RESULTS: Between 1998 and 2007, 816 women underwent surgery for stage 0-III breast cancer at our institution. Forty-five patients developed tumors. Univariate analysis showed the use of regional anesthesia trended towards reduced cancer recurrence, but it did not achieve statistical significance (p = 0.06). Higher recurrence rates were associated with ER positive status (p = 0.003) and higher tumor stage (p < 0.0001). Age and HER-2 status were not associated with increased cancer recurrence (both p > 0.11). Multivariate analysis confirmed ER status and stage as independently influential (p = 0.002 and p < 0.0001 respectively). CONCLUSION: Although we found a trend towards reduced breast cancer recurrence with the use of regional anesthesia, univariate analysis did not reach statistical significance.

Success of ultrasound guided popliteal sciatic nerve catheters is not influenced by nerve stimulation.

BACKGROUND: There is debate as to whether nerve stimulation (NS) is required to place peripheral nerve catheters when using ultrasound (US) guidance. There is conflicting evidence for whether stimulating catheters improve postoperative analgesia compared to non-stimulating catheters. The use of US in combination with NS has been shown to be superior to NS alone in terms of popliteal nerve blockade. Given the previously published reports, we hypothesized that there is improvement in sensory and motor blockade for stimulating popliteal perineural catheters placed under US guidance when NS is used. METHODS: Following IRB approval, 21 patients undergoing elective foot and ankle surgery were randomly assigned to either a US or US+NS-guided continuous popliteal sciatic nerve block using a lateral approach. The primary end-point of the study was successful nerve blockade at 20 minutes. Secondary end-points included: block performance time, minimum stimulating current, pain scores on postoperative day 1 and day 2, and patient satisfaction. RESULTS: There was no significant difference in successful nerve blockade at 20 minutes in the US versus US+NS groups (73% vs. 80%, p = 1). Procedure time was significantly shorter in the US only group (median 62 seconds vs. 130.5 seconds, p < 0.01). Postoperative pain scores and overall patient satisfaction were not significantly different between the two groups. CONCLUSION: We have found that the addition of NS provides no benefit over US alone. US alone was associated with a significantly shorter block performance time. US+NS showed no significant difference in pain control, patient satisfaction, or block success.

Advances in drug safety.

The operating room offers a unique setting where anesthetics, preoperative medications, patient comorbidities, and surgery all merge. Anesthesiologists are responsible for combining these concerns into a dependable and safe approach. From formulation to administration, enhancements in nearly every aspect of a given drug have improved the ability of anesthesiologists to accomplish this. Some of these methodologies, including novel anesthetics and analgesics, drug delivery and administration including infusion pumps, antithrombotics, and a reappraisal of previous medications are highlighted in this review. While these advancements are significant, patients and healthcare systems globally are rightfully demanding safer application of drugs at every level. On May 1, 2012, a report issued by the Institute of Medicine advised the United States Food and Drug Administration to undertake a much more rigorous patient-centered effort to evaluate a drug's safety over its entire life-cycle. This recommendation is in agreement with the objectives of the Anesthesia Patient Safety Foundation. With these mutual goals shared by many stakeholders and their continued efforts, the future of the estimated 200 million global surgeries to be undertaken this year hopefully provides a safer experience while under anesthesia.