Circumpsoas block ... an anterior myofascial plane block for lumbar plexus elements: case report.

In an attempt to improvise the analgesia in patients with femoral fractures, we aimed at depositing local anesthetic deep to anterior psoas fascia (APf) under ultrasound (US) guidance to block lumbar plexus elements which emerge lateral, anterior, and medial to the psoas major muscle. We termed this as circumpsoas block (CPB). Clinical and computed tomography contrast studies revealed that a continuous CPB infusion with a catheter provided a reliable block of the lumbar plexus elements. No adverse were events noted. We conclude that US guided CPB is a reliable technique for managing postoperative pain after surgery of femur fractures.

Circumpsoas block - an anterior myofascial plane block for lumbar plexus elements: case report

Abstract In an attempt to improvise the analgesia in patients with femoral fractures, we aimed at depositing local anesthetic deep to anterior psoas fascia (APf) under ultrasound (US) guidance to block lumbar plexus elements which emerge lateral, anterior, and medial to the psoas major muscle. We termed this as circumpsoas block (CPB). Clinical and computed tomography contrast studies revealed that a continuous CPB infusion with a catheter provided a reliable block of the lumbar plexus elements. No adverse were events noted. We conclude that US guided CPB is a reliable technique for managing postoperative pain after surgery of femur fractures.

An Ominous Cause of Headache in a Teenager.

We present the case of an adolescent male who presented to the emergency department with headache and vomiting. We discuss the differential diagnosis and the need to maintain a high index of suspicion to avoid missing ominous causes of headache. In this case, the patient had a pineoblastoma, detected on a noncontrast CT scan. The CT scan was done as part of the emergency department workup to evaluate headache accompanied by vomiting in this otherwise healthy teenager.

Anatomic and radiological correlation of injectate spread from first thoracic costotransverse junction in cervical erector spinae plane

Introduction Cervical erector spinae plane block (ESPB) provides postoperative pain relief when administered at the level of first thoracic costotransverse junction (CTJ) for surgeries on the proximal shoulder and cervical spine. We propose to describe the spread of 20 ml radiocontrast - dye solution administered at this level from caudad to cephalad direction in a fresh frozen cadaveric model through imaging and cross-sections. Methods An observational study with four thoracic to cervical ESP blocks at the level of first thoracic CTJ level on two fresh cadavers (total 4 specimens) was conducted using 20 ml of radiocontrast- methylene blue combination (10 ml through the needle and 10 ml through the catheter). Both cadavers were subjected to computed tomography (CT) scan. An anatomist and radiologist, respectively, analyzed cross-sections of cadavers and CT contrasted images. Results The spread was assessed in axial, sagittal, and coronal at the levels of C4, C5, C6, C7and T1. The medial limit was articular processes in both cadavers. The lateral limits were the outer border of the middle scalene muscle in cadaver 1 and posterior to the sternocleidomastoid muscle in cadaver 2. Contrast spread was visualized on the superior and anterior aspect of anterior scalene muscle in cadaver 2. An epidural spread was observed at the level of C5-6 and C6-7 in axial and coronal planes in cadaver 1. Conclusions The cervical ESPB administered at the first thoracic CTJ with injections directed cephalad has a consistent action on the dorsal spinal nerves of thoracic and cervical area, and spreads in the paravertebral space dorsal to the ventral cervical roots.

Neural Tube Defects in Pregnancies Among Women With Diagnosed HIV Infection - 15 Jurisdictions, 2013-2017.

In May 2018, a study of birth defects in infants born to women with diagnosed human immunodeficiency virus (HIV) infection in Botswana reported an eightfold increased risk for neural tube defects (NTDs) among births with periconceptional exposure to antiretroviral therapy (ART) that included the integrase inhibitor dolutegravir (DTG) compared with other ART regimens (1). The World Health Organization* (WHO) and the U.S. Department of Health and Human Services† (HHS) promptly issued interim guidance limiting the initiation of DTG during early pregnancy and in women of childbearing age with HIV who desire pregnancy or are sexually active and not using effective contraception. On the basis of additional data, WHO now recommends DTG as a preferred treatment option for all populations, including women of childbearing age and pregnant women. Similarly, the U.S. recommendations currently state that DTG is a preferred antiretroviral drug throughout pregnancy (with provider-patient counseling) and as an alternative antiretroviral drug in women who are trying to conceive.§ Since 1981 and 1994, CDC has supported separate surveillance programs for HIV/acquired immunodeficiency syndrome (AIDS) (2) and birth defects (3) in state health departments. These two surveillance programs can inform public health programs and policy, linkage to care, and research activities. Because birth defects surveillance programs do not collect HIV status, and HIV surveillance programs do not routinely collect data on occurrence of birth defects, the related data have not been used by CDC to characterize birth defects in births to women with HIV. Data from these two programs were linked to estimate overall prevalence of NTDs and prevalence of NTDs in HIV-exposed pregnancies during 2013-2017 for 15 participating jurisdictions. Prevalence of NTDs in pregnancies among women with diagnosed HIV infection was 7.0 per 10,000 live births, similar to that among the general population in these 15 jurisdictions, and the U.S. estimate based on data from 24 states. Successful linking of data from birth defects and HIV/AIDS surveillance programs for pregnancies among women with diagnosed HIV infection suggests that similar data linkages might be used to characterize possible associations between maternal diseases or maternal use of medications, such as integrase strand transfer inhibitors used to manage HIV, and pregnancy outcomes. Although no difference in NTD prevalence in HIV-exposed pregnancies was found, data on the use of integrase strand transfer inhibitors in pregnancy are needed to understand the safety and risks of these drugs during pregnancy.

Role of ultrasound guided epidural anesthesia for lower limb surgery in children with previously repaired meningomyelocele.

BACKGROUND: Children that have had a meningomyelocele repair often present for hip and bilateral lower limb surgeries. Due to vertebral, epidural, and nerve root abnormalities, placement of epidural catheter is difficult. AIMS: We aim to describe the potential role of ultrasound in delineating the most appropriate intervertebral space for central neuroaxial blocks in these patients. METHODS: Twelve children with previous meningomyelocele repair, in the age group of 6-12 years posted for hip or bilateral lower limb surgeries were included. After induction of anesthesia, an ultrasound scan was done with the patient in the left lateral position. The central neuroaxial block was performed in the most appropriate intervertebral space seen on transverse scan of spine. These patients were studied with regard to visibility of the osseous framework of the spine, the anterior and posterior dural complexes, ease of insertion of catheter, evidence of dural puncture, and possibility of identification of the extent of peri-incisional fibrosis. RESULTS: One case required 2 attempts. There was no evidence of dural puncture. We could confirm the soft tissue shadow, the osseous framework, and the anterior and posterior dural complexes in all 12 patients. Ultrasonography guided in selecting the most appropriate space for epidural catheter placement. CONCLUSION: Ultrasound guidance aids in identification of normal intervertebral space and explicitly shows the abnormal space. It can be used as an aid to differentiate between normal and abnormal space in post-meningomyelocele repair.

Repetitive Transcranial Magnetic Stimulation in Chronic Pain: A Meta-analysis.

BACKGROUND: In this meta-analysis, we explore the role of repetitive transcranial magnetic stimulation (rTMS), a noninvasive neuromodulation technique in the treatment of chronic pain. METHODS: Studies comparing rTMS and conventional treatment for chronic pain were searched. The comparison was made for decrease in the pain scores with and without (sham) the use of rTMS after a follow-up interval of 4-8 weeks. All reported pain scores were converted into a common scale ranging from "0" (no pain) to "10" (worst pain). RESULTS: Nine trials with 183 patients in each of the groups were included in the analysis. The decrease in pain scores with rTMS was 1.12 (95% confidence interval [CI] being 1.46-0.78) (fixed effects, I2 = 0%, P < 0.001) and in sham-rTMS was 0.28 (95% CI being 0.49-0.07) (Fixed effects, I2 = 0, P = 0.01). The pooled mean drop in pain scores with rTMS therapy was higher by 0.79 (95% CI being 0.26-1.33) (fixed effects, I2 = 0, P < 0.01). The duration and frequency of rTMS were highly variable across trials. Publication bias was unlikely (Egger's test, X-intercept = 0.13, P = 0.75). CONCLUSIONS: Use of rTMS improves the efficacy of conventional medical treatment in chronic pain patients. This treatment is not associated with any direct adverse effects. However, the duration and frequency of rTMS therapy is presently highly variable and needs standardization.

Comparison of dexamethasone and clonidine as an adjuvant to 1.5% lignocaine with adrenaline in infraclavicular brachial plexus block for upper limb surgeries.

BACKGROUND AND AIMS: The role of clonidine as an adjuvant to regional blocks to hasten the onset of the local anesthetics or prolong their duration of action is proven. The efficacy of dexamethasone compared to clonidine as an adjuvant is not known. We aimed to compare the efficacy of dexamethasone versus clonidine as an adjuvant to 1.5% lignocaine with adrenaline in infraclavicular brachial plexus block for upper limb surgeries. MATERIAL AND METHODS: Fifty three American Society of Anaesthesiologists-I and II patients aged 18-60 years scheduled for upper limb surgery were randomized to three groups to receive 1.5% lignocaine with 1:200,000 adrenaline and the study drugs. Group S (n = 13) received normal saline, group D (n = 20) received dexamethasone and group C (n = 20) received clonidine. The time to onset and peak effect, duration of the block (sensory and motor) and postoperative analgesia requirement were recorded. Chi-square and ANOVA test were used for categorical and continuous variables respectively and Bonferroni or post-hoc test for multiple comparisons. P < 0.05 was considered significant. RESULTS: The three groups were comparable in terms of time to onset and peak action of motor and sensory block, postoperative analgesic requirements and pain scores. 90% of the blocks were successful in group C compared to only 60% in group D (P = 0.028). The duration of sensory and motor block in group S, D and C were 217.73 ± 61.41 min, 335.83 ± 97.18 min and 304.72 ± 139.79 min and 205.91 ± 70.1 min, 289.58 ± 78.37 min and 232.5 ± 74.2 min respectively. There was significant prolongation of sensory and motor block in group D as compared to group S (P < 0.5). Time to first analgesic requirement was significantly more in groups C and D as compared with group S (P < 0.5). Clinically significant complications were absent. CONCLUSIONS: We conclude that clonidine is more efficacious than dexamethasone as an adjuvant to 1.5% lignocaine in brachial plexus blocks.

Confirmation of local anesthetic distribution by radio-opaque contrast spread after ultrasound guided infraclavicular catheters placed along the posterior cord in children: a prospective analysis.

BACKGROUND: The needle tip placed at the level of posterior cord under ultrasound guidance is described as the most effective way to obtain single shot successful block in adults, for forearm and hand surgeries. OBJECTIVE: The aim of this research was to study the spread of dye (depicting the local anesthetic) through catheters placed along the posterior cord. This was performed with continuous infraclavicular blocks placed under ultrasound guidance in children. METHODS: Twenty-four ASA 1 and 2 children, aged 7 months to 8 years old, scheduled for upper limb orthopedic surgeries were included in this prospective descriptive study. They received continuous infraclavicular block under ultrasound guidance. Skin markings were obtained from catheters that were placed below the posterior cord inserted 2-3 cm beyond the tip of the Tuohy needle. A radio-opaque dye was injected into the catheters and 5 min later, the dye spread was evaluated fluoroscopically. Postoperatively, all patients received a continuous infusion of 0.125% bupivacaine for pain relief. RESULTS: All 24 cases showed the presence of the dye along the neurovascular bundle in the infraclavicular region suggesting successful blocks. The mean ± standard deviation of the skin marking for the catheter was 5.61 ± 1.77 cm. Postoperatively, all patients had adequate pain relief with the catheters. One patient had break through pain on day 1 and four catheters were accidentally dislodged on day 2. CONCLUSION: We conclude that continuous infraclavicular catheters can be accurately and effectively placed along the posterior cord exclusively under ultrasound guidance in infants and small children.

Comparison of success rate of ultrasound-guided sciatic and femoral nerve block and neurostimulation in children with arthrogryposis multiplex congenita: a randomized clinical trial.

BACKGROUND AND OBJECTIVES: Arthrogryposis multiplex congenital is hallmarked with immobile joints and muscle fibrosis. The main objective of this study was to compare the success rate of ultrasound-guided sciatic and femoral nerve blocks with nerve stimulations in children diagnosed with distal arthrogryposis multiplex congenita. METHOD: Sixty children aged 8 months to 2 years posted for foot surgery were randomly assigned to group NS and group US of 30 each. Under general anesthesia, femoro-sciatic block was performed with nerve stimulator guidance in group NS and ultrasound guidance in group US. RESULTS: Group NS: 23 of 30 (76.7%) children showed ankle movement with sciatic neurostimulation. In 7 (23.6%), distal motor response could not be elicited and the block was abandoned. Out of 23 children who could be given femoral block, in 12 (52%) patients quadriceps contractions were not elicited and fascia iliaca block was given. All 23 blocks were successful. CHIPPS score at 1, 4, 6, 8, and 10 h was 1.05 ± 0.90, 1.82 ± 1.18, 3.36 ± 1.65, 2.23 ± 2.02, and 1.18 ± 1.14, respectively. Group US: In 29 of 30 patients (96.6%), sciatic nerve was visualized with ultrasonography. All 29 children received femoral block, and they were successful. The odds of success in group US were 8.9 (95% confidence interval [1.0, 77.9]) as compared with NS group. The difference in success rate was statistically significant (P = 0.026). The analgesic duration difference in the US and NS groups was a mean 7.62 ± 0.57 h in group NS and 8.60 ± 0.66 h in group US (statistically significant [P < 0.001]). CHIPPS score at 1, 4, 6, 8, and 10 h was 0.79 ± 0.96, 1.61 ± 0.92, 2.96 ± 1.04, 2.36 ± 2.54, and 1.14 ± 1.01, respectively. The difference between the CHIPPS score was not statistically significant. CONCLUSION: Ultrasonography significantly increases the success rate of sciatic and femoral block in arthrogryposis.

Feasibility and efficacy of placement of continuous sciatic perineural catheters solely under ultrasound guidance in children: a descriptive study.

BACKGROUND: Placement of sciatic catheters with ultrasound and stimulating catheters is known. Literature regarding catheter placements with only ultrasound is limited. We aimed to investigate the feasibility of performing continuous sciatic nerve block exclusively with ultrasound guidance and minimal equipment. METHOD: Forty ASA 1 and 2 patients aged 8 months-10 years posted for congenital talipoequinovarus surgery were included in the study. Continuous sciatic catheters were placed under ultrasound guidance with 18- gauge Tuohy needle at the infragluteal fold. Then, 0.25% of bupivacaine 0.5 ml·kg(-1) bolus was injected followed by continuous infusion later. Half the volume of the drug was injected prior to catheter insertion to improve visibility. The sciatic nerve, needle tip and shaft, catheter tip and the drug spread were visualized. The efficacy of the block intraoperatively and postoperatively was evaluated. RESULTS: The sciatic nerve, needle shaft, and tip were well visualized in all 40 patients. The catheter tip was seen in 72.5% of patients. The effect of block was complete intraoperatively and postoperatively. Clinically significant complications were absent. CONCLUSION: We conclude that in children, continuous sciatic catheters can be accurately and efficaciously placed with minimal equipment with ultrasound alone.