Permanent Peripheral Nerve Stimulator for Complex Regional Pain Syndrome of the Forearm and Hand.

A 51-year-old woman with diabetes and depression was referred to the anesthesia pain clinic with a 15-year history of complex regional pain syndrome type I of the right forearm and hand in the radial sensory nerve distribution. There was no recognized antecedent trauma and she had failed both medical treatment and radial sensory nerve decompression surgery. An ultrasound-guided local anesthetic block of the radial nerve in the upper arm resulted in partial and temporary improvement in pain. She subsequently underwent trial of a peripheral nerve stimulator (PNS) followed by permanent PNS implant placement over the radial nerve proper proximal to the elbow. Within the first month of use, she endorsed substantially improved pain and strength in her right hand. These improvements were sustained for more than 1 year. Applications of PNS technology for treatment of extremity complex regional pain syndrome and neuropathic extremity pain in general are reviewed.

Spinal Anesthesia or General Anesthesia for Hip Surgery in Older Adults.

BACKGROUND: The effects of spinal anesthesia as compared with general anesthesia on the ability to walk in older adults undergoing surgery for hip fracture have not been well studied. METHODS: We conducted a pragmatic, randomized superiority trial to evaluate spinal anesthesia as compared with general anesthesia in previously ambulatory patients 50 years of age or older who were undergoing surgery for hip fracture at 46 U.S. and Canadian hospitals. Patients were randomly assigned in a 1:1 ratio to receive spinal or general anesthesia. The primary outcome was a composite of death or an inability to walk approximately 10 ft (3 m) independently or with a walker or cane at 60 days after randomization. Secondary outcomes included death within 60 days, delirium, time to discharge, and ambulation at 60 days. RESULTS: A total of 1600 patients were enrolled; 795 were assigned to receive spinal anesthesia and 805 to receive general anesthesia. The mean age was 78 years, and 67.0% of the patients were women. A total of 666 patients (83.8%) assigned to spinal anesthesia and 769 patients (95.5%) assigned to general anesthesia received their assigned anesthesia. Among patients in the modified intention-to-treat population for whom data were available, the composite primary outcome occurred in 132 of 712 patients (18.5%) in the spinal anesthesia group and 132 of 733 (18.0%) in the general anesthesia group (relative risk, 1.03; 95% confidence interval [CI], 0.84 to 1.27; P = 0.83). An inability to walk independently at 60 days was reported in 104 of 684 patients (15.2%) and 101 of 702 patients (14.4%), respectively (relative risk, 1.06; 95% CI, 0.82 to 1.36), and death within 60 days occurred in 30 of 768 (3.9%) and 32 of 784 (4.1%), respectively (relative risk, 0.97; 95% CI, 0.59 to 1.57). Delirium occurred in 130 of 633 patients (20.5%) in the spinal anesthesia group and in 124 of 629 (19.7%) in the general anesthesia group (relative risk, 1.04; 95% CI, 0.84 to 1.30). CONCLUSIONS: Spinal anesthesia for hip-fracture surgery in older adults was not superior to general anesthesia with respect to survival and recovery of ambulation at 60 days. The incidence of postoperative delirium was similar with the two types of anesthesia. (Funded by the Patient-Centered Outcomes Research Institute; REGAIN ClinicalTrials.gov number, NCT02507505.).

Thoracoscopic lung biopsy under regional anesthesia for interstitial lung disease.

BACKGROUND: Interstitial lung disease (ILD) management guidelines support lung biopsy-guided therapy. However, the high mortality associated with thoracoscopic lung biopsy using general anesthesia (GA) in patients with ILD has deterred physicians from offering this procedure and adopt a diagnostic approach based on high-resolution CT. Here we report that thoracoscopy under regional anesthesia could be a safer alternative for lung biopsy and effectively guide ILD treatment. METHODS: This was a single-center retrospective review of prospectively maintained database and consisted of patients who underwent thoracoscopic lung biopsy between March 2016 and March 2018. Patients were divided into two groups: (A) GA, and (B) regional anesthesia using monitored anesthesia care (MAC) and thoracic epidural anesthesia (TEA). RESULTS: During the study period, 44 patients underwent thoracoscopic lung biopsy. Of these, 15 underwent MAC/TEA. There were no significant differences between the two groups with regard to pulmonary function test and clinicodemographic profile. However, operative time and hospital stay were shorter in MAC/TEA group (32.5±18.5 min vs 50.8±18.4; p=0.004, 1.0±1.3 days vs 10.0±34.7 days; p<0.001, respectively). Eight patients in the GA group, but none in the MAC/TEA group, experienced worsening of ILD after lung biopsy (p=0.03). Additionally, one patient in the GA group died due to acute ILD worsening. No cases of MAC/TEA group had to be converted to GA. In all cases a pathological diagnosis could be made. CONCLUSIONS: Thoracoscopy using regional anesthesia might be a safer alternative to lung biopsy in patients with ILD.

Transversus Abdominis Plane Blockade as Part of a Multimodal Postoperative Analgesia Plan in Patients Undergoing Radical Cystectomy.

BACKGROUND: Radical cystectomy (RC) is a morbid procedure with frequent complications that may benefit from implementation of an enhanced recovery after surgery (ERAS) protocol. OBJECTIVE: To examine the benefits of a multimodal analgesic plan that uses continuous transversus abdominis plane (TAP) blockade as part of an ERAS protocol after RC. METHODS: A retrospective comparison of consecutive patients undergoing RC over a 4-year period was conducted. Patients were designated as having surgery either before or after implementation of an ERAS protocol. A major component of the ERAS protocol was a multi-modal analgesia plan with TAP blockade. Patient demographics, comorbidities, operative details, and outcomes, including days to flatus, bowel movement (BM), narcotic usage, and length of stay (LOS) were compared. RESULTS: In total, 171 patients were included: 100 pre-ERAS and 71 ERAS. There were no differences in age, smoking status, operative approach, or diversion type. The patients in the ERAS cohort were less likely to be male, had a higher median BMI, and more likely to have received neoadjuvant chemotherapy. Total and early postoperative narcotic use were lower in the ERAS cohort: 89 vs. 336 mg (p < 0.001) and 62 vs 203 mg (p = 0.001), respectively. The ERAS cohort had fewer days to flatus (3 vs. 4, p < 0.001) and fewer days to bowel movement (4 vs. 5, p < 0.001). Median LOS was shorter in the ERAS cohort (7 vs. 8.5d, p = 0.001). There were no differences in complications or readmission rates between the two cohorts. CONCLUSIONS: TAP blockade as part of an ERAS multi-modal pain plan is associated with low narcotic usage, and significant improvement in time to flatus, BM, and LOS compared to traditional post-RC pain management.

The Effect of Intraoperative Systemic Lidocaine on Postoperative Persistent Pain Using Initiative on Methods, Measurement, and Pain Assessment in Clinical Trials Criteria Assessment Following Breast Cancer Surgery: A Randomized, Double-Blind, Placebo-Controlled Trial.

OBJECTIVE: To compare the incidence in postsurgical persistent pain following breast cancer surgery in women receiving intravenous lidocaine compared to saline using validated pain instruments in accordance with the Initiative on Methods, Measurement, and Pain Assessment in Clinical Trials (IMMPACT) recommendations. METHODS: The study was a randomized, double-blinded, placebo-controlled, clinical trial. Subjects were randomized into Group 1 (1.5 mg/kg bolus of intravenous lidocaine followed by a 2 mg/kg/hour infusion) or Group 2 (normal saline at the same bolus and infusion rate). Patients were evaluated at 3 and 6 months for the presence of chronic persistent postsurgical pain. RESULTS: One hundred forty-eight patients were included in the study analysis. There were no differences in quality of recovery, pain burden, or opioid consumption between groups at 24 hours. Pain (yes/no) at 6 months attributed to surgery was reported in 29% of Group 2 vs. 13% of Group 1 patients (P = 0.04); however, only 3 subjects (5%) in Group 1 and 2 subjects (3%) in Group 2 met IMMPACT criteria for persistent postoperative pain (P = 0.99). DISCUSSION: Perioperative infusion of lidocaine has been reported to decrease the incidence of postsurgical pain at 3 and 6 months following mastectomy using dichotomous (yes/no) scoring. Although intravenous lidocaine reduced the reported incidence of pain at rest at 6 months, pain with activity, pain qualities, and the physical or emotional impact of the pain were unaffected. Future studies evaluating postsurgical persistent pain should adhere to the IMMPACT recommendations in order to more accurately describe the effect of an intervention on persistent pain.

Effect of Arm Positioning on Entrapment of Infraclavicular Nerve Block Catheter.

Continuous brachial plexus nerve block catheters are commonly inserted for postoperative analgesia after upper extremity surgery. Modifications of the insertion technique have been described to improve the safety of placing an infraclavicular brachial plexus catheter. Rarely, these catheters may become damaged or entrapped, complicating their removal. We describe a case of infraclavicular brachial plexus catheter entrapment related to differences in arm positioning during catheter placement and removal. Written authorization to obtain, use, and disclose information and images was obtained from the patient.

Single-Dose Adductor Canal Block With Local Infiltrative Analgesia Compared With Local Infiltrate Analgesia After Total Knee Arthroplasty: A Randomized, Double-Blind, Placebo-Controlled Trial.

BACKGROUND AND OBJECTIVES: A single-dose adductor canal block can provide postoperative analgesia for patients undergoing total knee arthroplasty (TKA). The purpose of this study was to assess postoperative opioid consumption after ultrasound-guided single-injection bupivacaine compared with saline adductor canal block for patients undergoing TKA. METHODS: After institutional review board approval, written informed consent was obtained from patients (>18 years old) undergoing elective TKA. Subjects were randomized into 2 groups as follows: adductor canal blockade with 10 mL of bupivacaine 0.25% with epinephrine 1:300,000 or 10 mL of normal saline. All patients received a periarticular infiltration mixture intraoperatively with scheduled and patient requested oral and IV analgesics postoperatively for breakthrough pain. Personnel blinded to group allocation recorded pain scores and opioid consumption every 6 hours. Pain burden, area under the numeric rating score for pain, was calculated for 36 hours. The primary outcome was postoperative IV/IM morphine (mg morEq) consumption at 36 hours after surgery. RESULTS: Forty (28 women/12 men) subjects were studied. Postoperative opioid consumption was reduced in the bupivacaine 48 (39 to 61) mg morEq compared with saline 60 (49 to 85) mg morEq, difference -12 (-33 to -2) mg morEq (P = 0.03). Pain burden at rest was decreased in the bupivacaine 71 (37 to 120) score · hours compared with saline 131 (92 to 161) score · hours, difference -60 (-93 to -14) score · hours (P = 0.009). CONCLUSIONS: Adductor canal blockade with bupivacaine 0.25% with epinephrine 1:300,000 effectively reduces pain and opioid requirement in the postoperative period after TKA. Adductor canal blockade is an effective pain management adjunct for patients undergoing TKA.

Greater Cephalad Extent of Thoracic Epidural Sensory Anesthesia After Lidocaine and Epinephrine Test Dose Correlates With Analgesic Consumption and Pain Burden After Uterine Fibroid Artery Embolization.

BACKGROUND AND OBJECTIVES: Ischemic pain after uterine fibroid artery embolization (UFAE) is often severe. We evaluated the sensory anesthesia extent from thoracic epidural catheter test injection of lidocaine 75 mg with epinephrine 25 µg as a predictor of analgesia effectiveness after UFAE. METHODS: One hundred patients were studied. Pinprick and cold insensitivity were assessed from L3 to T4 at 5-minute intervals for 30 minutes after the test dose. Thoracic epidural management was standardized. Total epidural infusate and numeric rating of pain (0-10) scores were recorded. RESULTS: Pinprick or cold insensitivity at T9 to T10 dermatome was present in 94% of patients. Forty-six subjects (45%) achieved a sensory level at or above the T6 dermatome at 30 minutes. Median analgesic consumption in the first hour and at catheter discontinuation was greater in subjects with a sensory level above T6 compared with those below T6: first hour difference, 7 mL (95% confidence interval [95% CI], 0-12 mL; P = 0.02); difference at discontinuation, 21 mL (95% CI, 4-35 mL; P = 0.02). The area under the pain score by time curve for the first 24 hours was greater in patients with sensory levels above T6: difference 32 score · hour (95% CI, 12 score · h - 60 score · h; P = 0.001). CONCLUSIONS: Sensory anesthesia spread above the T6 dermatome 30 minutes after a test dose of 1.5% lidocaine was an independent predictor of the analgesic consumption after UFAE. Pain burden and oral opioid consumption were also increased in subjects who demonstrated a high sensory spread after the test dose.

Systemic lidocaine to improve quality of recovery after laparoscopic bariatric surgery: a randomized double-blinded placebo-controlled trial.

BACKGROUND: Few multimodal strategies to minimize postoperative pain and improve recovery have been examined in morbidly obese patients undergoing laparoscopic bariatric surgery. The main objective of this study was to evaluate the effect of systemic intraoperative lidocaine on postoperative quality of recovery when compared to saline. METHODS: The study was a prospective randomized, double-blinded placebo-controlled clinical trial. Subjects undergoing laparoscopic bariatric surgery were randomized to receive lidocaine (1.5 mg/kg bolus followed by a 2 mg/kg/h infusion until the end of the surgical procedure) or the same volume of saline. The primary outcome was the quality of recovery 40 questionnaire at 24 h after surgery. RESULTS: Fifty-one subjects were recruited and 50 completed the study. The global QoR-40 scores at 24 h were greater in the lidocaine group median (IQR) of 165 (151 to 170) compared to the saline group, median (IQR) of 146 (130 to 169), P = 0.01. Total 24 h opioid consumption was lower in the lidocaine group, median (IQR) of 26 (19 to 46) mg IV morphine equivalents compared to the saline group, median (IQR) of 36 (24 to 65) mg IV morphine equivalents, P = 0.03. Linear regression demonstrated an inverse relationship between the total 24 h opioid consumption (IV morphine equivalents) and 24 h postoperative quality of recovery (P < 0.0001). CONCLUSIONS: Systemic lidocaine improves postoperative quality of recovery in patients undergoing laparoscopic bariatric surgery. Patients who received lidocaine had a lower opioid consumption which translated to a better quality of recovery.

Ultrasound-guided trigeminal nerve block via the pterygopalatine fossa: an effective treatment for trigeminal neuralgia and atypical facial pain.

BACKGROUND: Patients presenting with facial pain often have ineffective pain relief with medical therapy. Cases refractory to medical management are frequently treated with surgical or minimally invasive procedures with variable success rates. We report on the use of ultrasound-guided trigeminal nerve block via the pterygopalatine fossa in patients following refractory medical and surgical treatment. OBJECTIVE: To present the immediate and long-term efficacy of ultrasound-guided injections of local anesthetic and steroids in the pterygopalatine fossa in patients with unilateral facial pain that failed pharmacological and surgical interventions. SETTING: Academic pain management center. STUDY DESIGN: Prospective case series. METHODS: Fifteen patients were treated with ultrasound-guided trigeminal nerve block with local anesthetic and steroids placed into the pterygopalatine fossa. RESULTS: All patients achieved complete sensory analgesia to pin prick in the distribution of the V2 branch of the trigeminal nerve and 80% (12 out of 15) achieved complete sensory analgesia in V1, V2, V3 distribution within 15 minutes of the injection. All patients reported pain relief within 5 minutes of the injection. The majority of patients maintained pain relief throughout the 15 month study period. No patients experienced symptoms of local anesthetic toxicity or onset of new neurological sequelae. LIMITATIONS: Prospective case series. CONCLUSION: We conclude that the use of ultrasound guidance for injectate delivery in the pterygopalatine fossa is a simple, free of radiation or magnetization, safe, and effective percutaneous procedure that provides sustained pain relief in trigeminal neuralgia or atypical facial pain patients who have failed previous medical interventions.

Nerve block of the infrapatellar branch of the saphenous nerve in knee arthroscopy: a prospective, double-blinded, randomized, placebo-controlled trial.

BACKGROUND: With the rising use of outpatient knee arthroscopy over the past decade, interest in peripheral nerve blocks during arthroscopy has increased. Femoral nerve blocks are effective but are associated with an inherent risk of the patient falling postoperatively because of quadriceps weakness. We studied blocks of the infrapatellar branch of the saphenous nerve, which produce analgesia in the knee that is similar to that resulting from a femoral nerve block but without associated quadriceps weakness. METHODS: Thirty-four patients were enrolled into each arm of this prospective, randomized, double-blinded trial comparing 10 mL of 0.25% bupivacaine used as a block of the infrapatellar branch of the saphenous nerve with a placebo during simple knee arthroscopy. Immediate outcome measures included Numeric Rating Scale (NRS) pain scores (0 to 10 points), mobility and discharge times, opioid usage, subjective adverse side effects, and forty-eight-hour anesthesia recovery surveys. Short-term measures included one-week and twelve-week Lysholm knee scores. RESULTS: No adverse effects or increased quadriceps weakness were observed following use of the nerve block. Improvement in early NRS scores and subjective nausea (p = 0.03) were detected. Patients for whom the block was successful also had improved twelve-week Lysholm knee scores (p = 0.04). No differences in opioid usage, mobility time, forty-eight-hour anesthesia recovery scores, or one-week Lysholm knee scores were found. CONCLUSIONS: No significant adverse effect or disadvantage was identified for blocks of the infrapatellar branch of the saphenous nerve used in simple knee arthroscopy. In addition to decreased early NRS scores and nausea, blocks of the infrapatellar branch of the saphenous nerve demonstrated potential benefit at twelve weeks after simple knee arthroscopy.

A randomized trial of epidural analgesia followed by continuous femoral analgesia compared with oral opioid analgesia on short- and long-term functional recovery after total knee replacement.

OBJECTIVE: The purpose of this study was to compare continuous femoral nerve analgesia to oral opioid analgesics after discontinuation of epidural analgesia following total knee replacement. DESIGN: Randomized prospective controlled parallel group trial. Setting. Large tertiary university teaching hospital in a major Midwestern city. Subjects. Sixty-two subjects were randomized to receive neuraxial anesthesia followed by either oral analgesics (N = 31) or continuous femoral nerve analgesia (N = 31). INTERVENTIONS: After discontinuation of epidural anesthesia on the morning after surgery, continuous femoral nerve analgesia (CFA), ropivacaine 25 mg bolus and 5 mg/h infusion was initiated. Catheters were removed 24 hours later. All subjects received oral opioid analgesics as needed. OUTCOME MEASURES: The primary outcome measure was knee flexion at 1 month. Physical therapy assessments, pain scores, opioid consumption, and patient satisfaction were assessed during hospitalization. Knee flexion, pain scores, and opioid consumption were collected at 1, 6, and 12 months, and health-related quality of life was collected at 6 and 12 months. RESULTS; The median difference (95% CI) in the change in knee flexion from baseline was 7.5 (0 to 15) degrees greater after CFA (P = 0.04) at 1 month. CFA subjects had greater compliance with physical therapy, reduced pain scores, and opioid requirements during hospitalization. Thromboembolic events occurred in 0/31 CFA vs 4/31 non-CFA subjects (P = 0.04). CONCLUSIONS: CFA for 24 hours following discontinuation of epidural analgesia was associated with lower pain scores, greater compliance with physical therapy, increased range of motion, reduced opioid analgesia use, and greater patient satisfaction during hospitalization. The increased flexion of the operated joint was still evident at 1 month postoperatively.

Nerve stimulator-guided supplemental popliteal sciatic nerve block after a failed sciatic block does not increase the incidence of transient postoperative neurologic sequelae.

BACKGROUND: Supplemental peripheral nerve blocks are not commonly performed in adults because of concerns of cumulative exposure of the nerve to the local anesthetic as well as increased ischemia from epinephrine. The purpose of this study was to compare the incidence of postoperative neurologic symptoms after a failed subgluteal sciatic nerve block and a supplemental popliteal sciatic nerve block. METHODS: Five hundred twelve adult patients undergoing ambulatory surgery were prospectively studied (1 yr). Sciatic nerve blocks were performed using levobupivacaine 0.625% with epinephrine 1:200,000 (0.5 ml/kg). Patients who failed to achieve sensory and motor anesthesia at 30-60 min were given a popliteal sciatic nerve block (lidocaine 2% 10 ml + levobupivacaine 0.5% 10 ml). Subjects were contacted at 24 h to 48 h, 2 weeks, and 1 month. Symptomatic patients were contacted biweekly and reevaluated during follow-up surgeon visits until symptom resolution. RESULTS: Four hundred thirty-nine subjects were analyzed. Fifty-six received a popliteal sciatic nerve block. Four subjects (0.9%) had self-reported neurologic symptoms in the distribution of the sciatic nerve. Investigator-initiated follow-up revealed 33 subjects (8.7%) who received a single subgluteal sciatic block and 4 subjects (7.1%) after a supplemental sciatic nerve block with neurologic symptoms (P = 0.80). The median duration of symptoms was 4 weeks (95% CI 3-5) in the subgluteal and 4 weeks (95% CI 3-5) weeks in the popliteal group (P = 0.98). All symptoms resolved by 14 weeks postprocedure. CONCLUSION: Blocking the sciatic nerve at a more distal site after a failed subgluteal sciatic nerve block does not appear to influence the incidence or duration of neurologic sequelae.

Factor VII levels and international normalized ratios in the early phase of warfarin therapy.

BACKGROUND: Factor VII is the most affected clotting factor during the early phase of warfarin therapy. An international normalized ratio (INR) of more than 1.4 is considered unsafe for epidural catheter placement or removal, according to the American Society of Regional Anesthesia and Pain Medicine. The authors tested the hypothesis that factor VII activities would be consistent with safe removal of the epidural catheter on postoperative day (POD) 1 regardless of INR value. METHODS: Data from 121 patients who took warfarin after undergoing total joint surgery and had INRs and factor VII levels determined were reviewed. Patient characteristics and factor VII activities were compared between patients with INRs of more than 1.4 and those with INRs less than or equal to 1.4 on PODs 1, 2, and 3. RESULTS: Eleven patients had INRs of more than 1.4 on POD 1; their mean +/- SD factor VII activities were 60 +/- 28% (normal: 50-160%). On POD 2, 78 patients with INRs more than of 1.4 had factor VII activities of 32 +/- 15%, whereas on POD 3, 84 patients with INRs of more than 1.4 had factor VII activities of 44 +/- 19%. Variables included in the final multiple logistic regression model as predictors of an INR of more than 1.4 on POD 2 were warfarin dose on POD 1 and factor VII activity on POD 2. CONCLUSIONS: The range of factor VII activities in the patients with INRs of more than 1.4 within 12 h of warfarin therapy was compatible with adequate hemostasis. The authors found no evidence that epidural catheters should not be removed even with INRs up to 1.9, the highest INR on POD 1 noted in their study.

Sensory testing of distal sural and posterior tibial nerves provides early prediction of surgical anesthesia after single-injection infragluteal-parabiceps sciatic nerve block.

BACKGROUND: Surgical anesthesia for reconstructive ankle surgery requires sensory and motor block of all the terminal nerve distributions of the sciatic nerve. In this prospective observational study, we investigated the value of sensory and motor testing of the foot, after local anesthetic injection, for predicting complete sciatic nerve blockade and the duration of testing required for identifying incomplete anesthesia. METHODS: Sciatic nerve blocks (n = 180) using the infragluteal-parabiceps approach were performed in patients undergoing reconstructive ankle surgery. Levobupivacaine 0.625% with epinephrine 1:300,000 (0.4 mL/kg) was injected after obtaining an elicited motor response at <0.4 mA of plantar flexion or inversion. Pinprick sensory assessments were performed at intervals by an observer unaware of the elicited motor response in the distal cutaneous distributions of the superficial peroneal nerve, deep peroneal nerve, posterior tibial nerve, and sural nerve. Motor block was assessed using foot (plantar flexion and dorsiflexion) movement and toe movement. A complete block was defined as sensory and motor loss in all distributions of the sciatic nerve within 25 minutes of local anesthetic injection. The optimal sensitivity and specificity of various cutoff times of sensory and motor testing were determined by receiver operating characteristic analysis. The area under the curves was compared for equivalence using nonparametric methods. The cutoff times were determined as the point of intersection of the lines of sensitivity and specificity. RESULTS: The elicited evoked motor response before sciatic nerve block was plantar flexion in 87 patients and inversion in 93. Eighty-eight of 93 patients (94.6%) who had an elicited motor response of inversion and 49 of 87 (55.7%) who had an elicited motor response of plantar flexion achieved complete sciatic nerve block at 25 minutes. Area under the curves were not different among testing paradigms. Receiver operating characteristic analysis identified optimal testing times of 4 minutes for the sural and 6 minutes for the posterior tibial nerve with an elicited motor response of inversion and 6 minutes with an elicited motor response of plantar flexion. No subject with an incomplete block achieved sural anesthesia by 10 minutes. CONCLUSION: Sural anesthesia assessed at the lateral heel and the lateral aspect of the foot and the fifth toe identified within 4 to 6 minutes demonstrated a similar posttest predictive value as anesthesia in the distributions of the posterior tibial and peroneal nerves or motor movement of the foot at later intervals. In addition, failure to achieve sural anesthesia within 10 minutes was predictive of block failure.

A randomized comparison of a modified intertendinous and classic posterior approach to popliteal sciatic nerve block.

INTRODUCTION: In this prospective randomized study, we compared a single-injection modified intertendinous (n = 55) with the classic posterior (n = 54) popliteal sciatic nerve block for patients undergoing ankle/foot surgery. METHODS: Nerve stimulator-guided blocks were performed 7-8 cm (classic posterior) or 12-14 cm (modified intertendinous) above the popliteal crease. Levobupivacaine 0.625% with epinephrine 1:300,000 (Chirocaine(R), Purdue Pharma, Stamford, CT), was injected in 5 mL aliquots to a total volume of 0.4 mL/kg (range, 25-35 mL). The needle position was considered acceptable if an evoked motor response of plantar flexion, inversion, eversion or a dorsiflexion of the ipsilateral foot was elicited at

Neurologic sequelae after interscalene brachial plexus block for shoulder/upper arm surgery: the association of patient, anesthetic, and surgical factors to the incidence and clinical course.

We determined the incidence, distribution, and resolution of neurologic sequelae and the association with anesthetic, surgical, and patient factors after single-injection interscalene block (ISB) using levobupivacaine 0.625% with epinephrine 1:200,000 in subjects undergoing shoulder or upper arm surgery, or both, in 693 consecutive adult patients. After a standardized ISB, assessments were made at 24 and 48 h and at 2 and 4 wk for anesthesia, hypesthesia, paresthesias, pain/dysesthesias, and motor weakness. Symptomatic patients were monitored until resolution. Subjects reporting pain or discomfort >3 of 10 and those with motor or extending sensory symptoms received diagnostic assessment. Six-hundred-sixty subjects completed 4 wk of follow-up. Fifty-eight neurologic sequelae were reported by 56 subjects. Symptoms were sensory except for two cases of motor weakness (lesions identified distant from the ISB site). Thirty-one sequelae with likely ISB association were reported by 29 subjects, including 14 at the ISB site, 9 at the distal phalanx of thumb/index finger, 7 involving the posterior auricular nerve, and 1 clinical brachial plexopathy. Sequelae not likely associated with the ISB were reported by 27 subjects with symptoms reported in the median (n = 9) and ulnar (n = 4) nerves, surgical neuropraxias (n = 12), and motor weakness (n = 2). Symptoms resolved spontaneously (median 4 wk; range, 2-16 wk) except in the two patients with motor weaknesses and the patient with clinical brachial plexopathy, who received therapeutic interventions. Variables identified as independent predictors of neurologic sequelae likely related to ISB were paresthesia at needle insertion and ISB site pain or bruising at 24 h. In contrast, surgery preformed in the sitting position, as well as ISB site bruising, was identified as a predictor of neurologic sequelae not likely related to ISB. In conclusion, neurologic sequelae after single-injection ISB using epinephrine mainly involve transient minor sensory symptoms.

Nerve stimulator-assisted evoked motor response predicts the latency and success of a single-injection sciatic block.

Variable onset latency of single-injection sciatic nerve block (SNB) may result from drug deposition insufficiently close to all components of the nerve. We hypothesized that this variability is caused by the needle tip position relative to neural components, which is objectified by the type of evoked motor response (EMR) elicited before local anesthetic injection. One-hundred ASA I-II patients undergoing reconstructive ankle surgery received infragluteal-parabiceps SNB using 0.4 mL/kg (maximum 35 mL) of levobupivacaine 0.625%. The end-point for injection was the first elicited EMR: inversion (I), plantar flexion (PF), dorsiflexion (DF), or eversion (E) at 0.2-0.4 mA. The frequencies of the EMRs were: I 40%, PF 43%, E 14%, and DF 3%. SNB was considered complete if both tibial and common peroneal nerves were blocked and failed if either analgesia to pinprick was not observed at 30 min or anesthesia at 60 min. Patients with an EMR of I demonstrated shorter mean times (+/-95% confidence interval [CI]) to complete the block with 8.5 (95% CI, 6.2-10.8) min compared to 27.0 (95% CI, 20.6-33.4) min after PF (P < 0.001) and 30.4 (95% CI, 24.9-35.8) min after E (P < 0.001). No rescue blocks were required in group I compared with 24% (P = 0.001) and 71% (P < 0.001) of patients in groups PF and E, respectively. We conclude that EMR type during nerve stimulator-assisted single-injection SNB predicts latency and success of complete SNB because the observed EMR is related to the positioning of the needle tip relative to the tibial and common peroneal nerves.