Shrug radiographs for the diagnosis of long thoracic nerve palsy in traumatic brachial plexus injury.

BACKGROUND: Preoperative diagnosis of long thoracic nerve (LTN) palsy is important for shoulder reconstruction after a traumatic brachial plexus injury (BPI). In the present study, we developed an objective diagnostic method for LTN palsy for patients with traumatic BPI. METHODS: This is a retrospective review of 56 patients with traumatic BPI who had been receiving treatment at a single institution for over 8 years. The patients were divided into 2 groups: an LTN palsy group (n = 30) and a no palsy control group (n = 26). The LTN palsy group had 21 different palsy types with 4 and 5 C5-7 and C5-8, whereas the no palsy group had 18 different palsy types with 5 and 3 C5-6 and C5-8, respectively. Preoperative plain anteroposterior radiographs were taken in shoulder adduction and shrug positions. Scapulothoracic (ST) upward rotation and clavicle lateral (CL) rotation angles were measured on X-rays. The differences between the adduction and shrug positions for the respective angles were calculated and defined as ΦST and ΦCL, respectively. The differences in the ΦST and ΦCL values due to the presence or absence of LTN palsy were examined, the cutoff values of ΦST and ΦCL for the diagnosis of LTN palsy were determined, and further sensitivity and specificity were calculated. RESULTS: Both ΦST and ΦCL were significantly decreased in the LTN palsy group compared with the no palsy control group. The sensitivity and specificity for LTN palsy were 0.833 and 1.000 for ΦST and 0.833 and 0.840 for ΦCL, respectively, when the cutoff value was set as ΦST = 15° and ΦCL ≤ 24°. CONCLUSION: Dynamic shrug radiographs provide a useful objective diagnosis of LTN palsy after traumatic BPI.

Cryoneurolysis in Patients with Dorsal Neuropathic Pain Secondary to Tumor Invasion.

PURPOSE: To evaluate the safety and efficacy of cryoneurolysis (CNL) in patients with refractory thoracic neuropathic pain related to tumor invasion. MATERIALS AND METHODS: Between January 2013 and May 2017, this single-center and retrospective study reviewed 27 computed tomography-guided CNLs performed on 26 patients for refractory thoracic neuropathic pain related to tumor invasion. Patients with cognitive impairment were excluded. Pain levels were recorded on a visual analog scale (VAS) before the procedure, on days 1, 7, 14, 28 and at each subsequent follow-up appointment. CNL was clinically successful if the postprocedural VAS decreased by 3 points or more. To determine the duration of clinical success, the end of pain relief was defined as either an increased VAS of 2 or more points, the introduction of a new analgesic treatment, a death with controlled pain, or for lost to follow-up patients, the latest follow-up appointment date with controlled pain. RESULTS: Technical success rate was 96.7% and clinical success rate was 100%. Mean preprocedural pain score was 6.4 ± 1.7 and decreased to 2.4 ± 2.4 at day 1; 1.8 ± 1.7 at day 7 (P < .001); 3.3 ± 2.5 at day 14; 3.4 ± 2.6 at day 28 (P < .05). The median duration of pain relief was 45 days (range 14-70). Two minor complications occurred. CONCLUSIONS: Cryoneurolysis is a safe procedure that significantly decreased pain scores in patients with thoracic neuropathic pain related to tumor invasion, with a median duration of clinical success of 45 days.

Schwannoma of the long thoracic nerve in the left axilla: a case report.

Schwannoma, which is also known as neurilemmoma, is a type of tumor that arises from the peripheral nerve sheaths. Cases of schwannomas located in different regions have been reported. Some schwannomas present as asymptomatic masses, while others cause discomfort, such as pain and numbness. Magnetic resonance imaging (MRI) is a valuable diagnostic tool. A 23-year-old woman presented to our hospital with a mass in the left axilla that was misdiagnosed as mammae erraticae. The patient also considered the condition to be mammae erraticae for approximately 14 months because of a lack of symptoms. MRI was recommended by a surgeon from the galactophore department. A giant schwannoma was found. The mass was surgically excised, while preserving the continuity of the long thoracic nerve. Routine histopathological analysis confirmed the presence of a benign schwannoma. Schwannomas located in the axilla are rare and may be easily misdiagnosed as mammae erraticae or enlarged lymph nodes. Early investigation is necessary to make the diagnosis, and surgical excision is usually curative.

PECS, serratus plane, erector spinae, and paravertebral blocks: A comprehensive review.

Thoracic planar blocks represent a novel and rapidly expanding facet of regional anesthesia. These recently described techniques represent the potential for excellent analgesia, enhanced technical safety profiles, and reduced physiological side effects versus traditional techniques in thoracic anesthesia. Regional techniques, particularly those described in this review, have potential implications for mitigation of surgical pathophysiological neurohumoral changes. In the present investigation, we describe the history, common indications, technique, and limitations of pectoral nerves (PECS), serratus plane, erector spinae plane, and thoracic paravertebral plane blocks. In summary, these techniques provide excellent analgesia and merit consideration in thoracic surgery.

Comparison of the Efficacy of Ultrasound-Guided Serratus Anterior Plane Block, Pectoral Nerves II Block, and Intercostal Nerve Block for the Management of Postoperative Thoracotomy Pain After Pediatric Cardiac Surgery.

OBJECTIVE: The aim of this study was to compare the relative efficacy of ultrasound-guided serratus anterior plane block (SAPB), pectoral nerves (Pecs) II block, and intercostal nerve block (ICNB) for the management of post-thoracotomy pain in pediatric cardiac surgery. DESIGN: A prospective, randomized, single-blind, comparative study. SETTING: Single-institution tertiary referral cardiac center. PARTICIPANTS: The study comprised 108 children with congenital heart disease requiring surgery through a thoracotomy. INTERVENTIONS: Children were allocated randomly to 1 of the 3 groups: SAPB, Pecs II, or ICNB. All participants received 3 mg/kg of 0.2% ropivacaine for ultrasound-guided block after induction of anesthesia. Postoperatively, intravenous paracetamol was used for multimodal and fentanyl was used for rescue analgesia. MEASUREMENTS AND MAIN RESULTS: A modified objective pain score (MOPS) was evaluated at 1, 2, 4, 6, 8, 10, and 12 hours post-extubation. The early mean MOPS at 1, 2, and 4 hours was similar in the 3 groups. The late mean MOPS was significantly lower in the SAPB group compared with that of the ICNB group (p < 0.001). The Pecs II group also had a lower MOPS compared with the ICNB group at 6, 8, and 10 hours (p < 0.001), but the MOPS was comparable at hour 12 (p = 0.301). The requirement for rescue fentanyl was significantly higher in ICNB group in contrast to the SAPB and Pecs II groups. CONCLUSION: SAPB and Pecs II fascial plane blocks are equally efficacious in post-thoracotomy pain management compared with ICNB, but they have the additional benefit of being longer lasting and are as easily performed as the traditional ICNB.

Comparison of the effects of modified pectoral nerve block and erector spinae plane block on postoperative opioid consumption and pain scores of patients after radical mastectomy surgery: A prospective, randomized, controlled trial.

STUDY OBJECTIVE: Breast cancer is the most common malignancy of women all over the world. In this study, we compared the effects of ultrasound-guided modified pectoral nerve (PECS) block and erector spinae plane (ESP) block on postoperative opioid consumption, pain scores, and intraoperative fentanyl need of patients undergoing unilateral modified radical mastectomy surgery. DESIGN: Single-blinded, prospective, randomized, efficacy study. SETTING: Tertiary university hospital, postoperative recovery room and surgical ward. PATIENTS: Forty patients (ASA I-II) were allocated to two groups. After exclusion, 38 patients were included in the final analysis (18 patients in the PECS groups and 20 in the ESP group). INTERVENTIONS: Modified pectoral nerve block was performed in the PECS group and erector spinae plane block was performed in the ESP group. MEASUREMENTS: Postoperative tramadol consumption and pain scores were compared between the groups. Also, intraoperative fentanyl need was measured. MAIN RESULTS: Postoperative tramadol consumption was 132.78 ±â€¯22.44 mg in PECS group and 196 ±â€¯27.03 mg in ESP group (p = 0.001). NRS scores at the 15th and 30th min were similar between the groups. However, median NRS scores were significantly lower in PECS group at the postoperative 60th min, 120th min, 12th hour and 24th hour (p = 0.024, p = 0.018, p = 0.021 and p = 0.011 respectively). Intraoperative fentanyl need was 75 mg in PECS group and 87.5 mg in ESP group. The difference was not statistically significant (p = 0.263). CONCLUSION: Modified PECS block reduced postoperative tramadol consumption and pain scores more effectively than ESP block after radical mastectomy surgery.

Pectoral Fascial (PECS) I and II Blocks as Rescue Analgesia in a Patient Undergoing Minimally Invasive Cardiac Surgery.

INTRODUCTION: Patients undergoing minimally invasive cardiac surgery have the potential for significant pain from the thoracotomy site. We report the successful use of pectoral nerve block types I and II (Pecs I and II) as rescue analgesia in a patient undergoing minimally invasive mitral valve repair. CASE REPORT: In this case, a 78-year-old man, with no history of chronic pain, underwent mitral valve repair via right anterior thoracotomy for severe mitral regurgitation. After extubation, he complained of 10/10 pain at the incision site that was minimally responsive to intravenous opioids. He required supplemental oxygen because of poor pulmonary mechanics, with shallow breathing and splinting due to pain, and subsequent intensive care unit readmission. Ultrasound-guided Pecs I and II blocks were performed on the right side with 30 mL of 0.2% ropivacaine with 1:400,000 epinephrine. The blocks resulted in near-complete chest wall analgesia and improved pulmonary mechanics for approximately 24 hours. After the single-injection blocks regressed, a second set of blocks was performed with 266 mg of liposomal bupivacaine mixed with bupivacaine. This second set of blocks provided extended analgesia for an additional 48 hours. The patient was weaned rapidly from supplemental oxygen after the blocks because of improved analgesia. CONCLUSIONS: Pectoral nerve blocks have been described in the setting of breast surgery to provide chest wall analgesia. We report the first successful use of Pecs blocks to provide effective chest wall analgesia for a patient undergoing minimally invasive cardiac surgery with thoracotomy. We believe that these blocks may provide an important nonopioid option for the management of pain during recovery from minimally invasive cardiac surgery.

MR neurography (MRN) of the long thoracic nerve: retrospective review of clinical findings and imaging results at our institution over 4 years.

OBJECTIVE: Long thoracic nerve (LTN) injury can result in ipsilateral serratus anterior palsy and scapular winging. Traditional means of evaluating patients with suspected LTN injury include physical examination and electrodiagnostic studies. The purpose of our study is to describe high-resolution magnetic resonance (MR) findings in patients with clinical suspicion of LTN neuropathy. METHODS: In this HIPAA-compliant, IRB-approved, retrospective study, two radiologists reviewed MR imaging performed for long thoracic neuropathy. Clinical presentation, electrodiagnostic studies and MR imaging of 20 subjects [mean age 37 ± 13 years; 25% (5/20) female] were reviewed. Observers reviewed MR imaging for LTN signal intensity, size, course, presence or absence of mass and secondary findings [skeletal muscle denervation (serratus anterior, trapezius, rhomboid) and scapular winging]. Descriptive statistics were reported. RESULTS: Clinical indications included trauma (n = 5), hereditary neuropathy (n = 1), pain (n = 8), winged scapula (n = 6), brachial plexitis (n = 4) and mass (n = 1). Electrodiagnostic testing (n = 7) was positive for serratus anterior denervation in three subjects. Abnormal LTN signal intensity, size, course or mass was present in 0/20. Secondary findings included skeletal muscle denervation in the serratus anterior in 40% (8/20), trapezius in 20% (4/20) and rhomboid in 20% (4/20). In 5% (1/20), an osteochondroma simulated a winged scapula, and in 2/20 (10%) MR showed scapular winging. CONCLUSIONS: High-resolution MR imaging is limited in its ability to visualize the long thoracic nerve directly, but does reveal secondary signs that can confirm a clinical suspicion of LTN injury.

"Isolated long thoracic nerve palsy": More than meets the eye.

INTRODUCTION: Two main hypotheses have been proposed for the pathophysiology of long thoracic nerve (LTN) palsy: nerve compression and nerve inflammation. We hypothesized that critical reinterpretation of electrodiagnostic (EDX) studies and MRIs of patients with a diagnosis of non-traumatic isolated LTN palsy could provide insight into the pathophysiology and, potentially, the treatment. MATERIAL AND METHODS: A retrospective review was performed of all patients with a diagnosis of non-traumatic isolated LTN palsy and an EDX and brachial plexus or shoulder MRI studies performed at our institution. The original EDX studies and MR examinations were reinterpreted by a neuromuscular neurologist and musculoskeletal radiologist, respectively, both blinded to our hypothesis. RESULTS: Seven patients met the inclusion criteria as having a non-traumatic isolated LTN palsy. Upon reinterpretation, all of them were found to have findings not consistent with an isolated LTN. On physical examination, three of them (43%) presented with weakness in muscles not innervated by the LTN. Four of them (57%) had additional EDX abnormalities beyond the distribution of the LTN. Five of them (71%) had MRI evidence of enlargement of nerves or denervation atrophy of muscles outside the innervation of the LNT, without evidence of compression of the LTN in the middle scalene muscle. CONCLUSION: In our series, all 7 patients, originally diagnosed as having an isolated LTN, on reinterpretation, were found to have a more diffuse muscle/nerve involvement pattern, without MR findings to suggest nerve compression. These data strongly support an inflammatory pathophysiology.

Computed Tomography-Guided Percutaneously Controlled Ablation of the Thoracic Paravertebral Nerve Due to Thoracic Neuropathic Pain.

BACKGROUND: Patients with thoracic neuropathic pain often do not respond to medication and physical therapy. Coblation technology has been demonstrated to have potential for pain management. METHODS: Fifteen patients underwent computed tomography-guided percutaneous coblation to ablate the thoracic paravertebral nerve for their medication-resistant thoracic neuropathic pain. The pain intensity was assessed by visual analog scale (VAS) 1 day before surgery and 1 week and 1, 3, and 6 months after surgery, and the difference between preoperative and postoperative VAS values was determined to evaluate the pain relief effectiveness. Patients who achieved > 50% pain relief were defined as responders, and the ratio in all patients was calculated. The number of patients who reported mild pain (VAS ≤ 3) was recorded, and the ratio in all responders was calculated. In addition, adverse effects were also recorded to investigate the security of procedure. RESULTS: Twelve (80%) responders achieved > 50% pain relief. The VAS score of responders significantly decreased from 7.42 ± 1.38 before surgery to 2.17 ± 1.11 (P = 0.000), 1.92 ± 1.16 (P = 0.000), 1.75 ± 0.97 (P = 0.000), and 1.58 ± 1.08 (P = 0.000) at 1 week, 1, 3, and 6 months after surgery, respectively. The number of responders with mild pain was 10 (83.3%), 11 (91.7%), 12 (100%), and 12 (100%) at 1 week, 1, 3, and 6 months after surgery, respectively. All responders and 1 nonresponder reported slight numbness after the surgery. CONCLUSION: Percutaneous thoracic paravertebral nerve coblation guided by computed tomography is a potential method for the treatment of thoracic neuropathic pain.

Evaluation of Ultrasound-Assisted Thoracic Epidural Placement in Patients Undergoing Upper Abdominal and Thoracic Surgery: A Randomized, Double-Blind Study.

BACKGROUND AND OBJECTIVES: The placement of thoracic epidurals can be technically challenging and requires a thorough understanding of neuraxial anatomy. Although ultrasound imaging of the thoracic spine has been described, no outcome studies on the use of this imaging have been performed. We evaluated whether preprocedural ultrasound of the thoracic spine would facilitate the process of epidural catheterization. METHODS: Subjects undergoing thoracic or upper abdominal surgery with planned thoracic epidural placement at T10 or higher were enrolled in this randomized double-blind study. Subjects were allocated into 1 of 2 groups for preoperative epidural placement: ultrasound guidance (group US) or palpation (group Palp). Subjects randomized to group US had a preprocedural ultrasound examination to identify pertinent spinal anatomy and make appropriate marks on the skin identifying midline and interlaminar spaces for targeted Tuohy needle insertion. Subjects in group Palp had a skin marking performed by palpation alone. Using the skin markings, all epidurals were performed using a loss of resistance to saline technique. Block levels were assessed with ice and pain scores obtained by a blinded nurse in the postanesthesia care unit. The primary outcome was procedural time from needle insertion to loss of resistance in the epidural space. RESULTS: Seventy subjects were recruited and completed the study protocol. The median time for epidural needle placement to achieve loss of resistance in group US and group Palp was 188.5 seconds (interquartile range [IQR], 79.0-515.0) and 242.0 seconds (IQR, 87.0-627.0), respectively (P = 0.188). Using ultrasound to mark the skin overlying the targeted epidural space took a median time of 85 seconds (IQR, 69-113) for group US and 35 seconds (IQR, 27-51) for group Palp (P < 0.001). The number of needle passes was not significantly different between the 2 groups (P = 0.31). The use of ultrasound assistance resulted in a decreased number of needle skin punctures to achieve loss of resistance (P = 0.005). Mean pain scores after surgery were lower in group US compared to group Palp: 3.0 versus 4.7, respectively (P = 0.015). CONCLUSIONS: This is the first randomized study to evaluate the efficacy of preprocedural ultrasound marking for placement of thoracic epidural catheters. We observed that preprocedural ultrasound did not significantly reduce the time required to identify the thoracic epidural space via loss of resistance. CLINICAL TRIALS REGISTRATION: NCT02785055 (https://clinicaltrials.gov/).

The Erector Spinae Plane Block: A Novel Analgesic Technique in Thoracic Neuropathic Pain.

Thoracic neuropathic pain is a debilitating condition that is often poorly responsive to oral and topical pharmacotherapy. The benefit of interventional nerve block procedures is unclear due to a paucity of evidence and the invasiveness of the described techniques. In this report, we describe a novel interfascial plane block, the erector spinae plane (ESP) block, and its successful application in 2 cases of severe neuropathic pain (the first resulting from metastatic disease of the ribs, and the second from malunion of multiple rib fractures). In both cases, the ESP block also produced an extensive multidermatomal sensory block. Anatomical and radiological investigation in fresh cadavers indicates that its likely site of action is at the dorsal and ventral rami of the thoracic spinal nerves. The ESP block holds promise as a simple and safe technique for thoracic analgesia in both chronic neuropathic pain as well as acute postsurgical or posttraumatic pain.

[Difference in the Spread of Injectate between Ultrasound Guided Pectoral Nerve Block I and II. A Cadaver Study].

BACKGROUND: Pectoral nerve block (PECS block) is first reported by Blanco et al, and mainly used for analgesia for breast surgery in Japan. However, the spread of PECS block is unclear. METHODS: Ultrasound guided PECS I and II blocks were performed in a cadaver, and the cadaver was dissected for evaluation of the spread of coloring matter. RESULTS: The coloring matter by PECS I block was spread to the axillary region between the major and minor pectoral muscles, while PECS II block remained over the fascia of the serratus muscle from mid-clavicular line to middle axillary line. Two possible routes to the axillary region by PECS I include: dorsal to the pectoral minor muscle through the clavipectoral fascia, and over the pectoral minor muscle to the axillary sheath. CONCLUSIONS: Our cadaveric evaluation suggests that PECS I block produces more analgesia of the axillary region than PECS II. Further evaluation is needed in more cadavers.

Thoracic Nerve Root Entrapment by Intrathecal Catheter Coiling: Case Report and Review of the Literature.

BACKGROUND: Intrathecal catheter placement has long-term therapeutic benefits in the management of chronic, intractable pain. Despite the diverse clinical applicability and rising prevalence of implantable drug delivery systems in pain medicine, the spectrum of complications associated with intrathecal catheterization remains largely understudied and underreported in the literature. OBJECTIVE: To report a case of thoracic nerve root entrapment resulting from intrathecal catheter migration. STUDY DESIGN: Case report. SETTING: Inpatient hospital service. RESULTS/ CASE REPORT: A 60-year-old man status post implanted intrathecal (IT) catheter for intractable low back pain secondary to failed back surgery syndrome returned to the operating room for removal of IT pump trial catheter after experiencing relapse of preoperative pain and pump occlusion. Initial attempt at ambulatory removal of the catheter was aborted after the patient reported acute onset of lower extremity radiculopathic pain during the extraction. Noncontrast computed tomography (CT) subsequently revealed that the catheter had ascended and coiled around the T10 nerve root. The patient was taken back to the operating room for removal of the catheter under fluoroscopic guidance, with possible laminectomy for direct visualization. Removal was ultimately achieved with slow continuous tension, with complete resolution of the patient's new radicular symptoms. LIMITATIONS: This report describes a single case report. CONCLUSION: This case demonstrates that any existing loops in the intrathecal catheter during initial implantation should be immediately re-addressed, as they can precipitate nerve root entrapment and irritation. Reduction of the loop or extrication of the catheter should be attempted under continuous fluoroscopic guidance to prevent further neurosurgical morbidity.

Visualization of the Long Thoracic Nerve using High-Resolution Sonography.

PURPOSE: The long thoracic nerve (LTN) innervates the serratus anterior muscle (SA) which plays an important role in shoulder function. Evaluation of the LTN has so far been restricted to clinical assessment and partly electromyography and neurography. Progress of high-resolution ultrasound (HRUS) increasingly enables visualization of small peripheral nerves and their pathologies. We therefore aimed at (a) clarifying the possibility of visualization of the LTN from its origin to the most distal point in the supraclavicular region visible and (b) developing an ultrasound protocol for routine use. We further present two cases of patients with LTN pathology. METHODS: The study consisted of two parts: Part 1 included 4 non-enbalmed human bodies in whom the LTN (n = 8) was located and then marked by ink injection. Correct identification was confirmed by anatomical dissection. Part 2 included 20 healthy volunteers whose LTN (n = 40) was assessed independently by two radiologists. Identification of the LTN was defined as consensus in recorded images. RESULTS: LTN was clearly visible in all anatomical specimens and volunteers using HRUS and could be followed until the second slip of the serratus anterior muscle from the supraclavicular region. In anatomical specimens, dissection confirmed HRUS findings. For all volunteers, consensus was obtained. The mean nerve diameter was 1.6 mm ±â€Š0.3 (range 1.1 - 2.1 mm) after the formation of the main trunk. DISCUSSION: We hereby confirm a reliable possibility of visualization of the LTN in anatomical specimens as well as in volunteers. We encourage HRUS of the LTN to be part of the diagnostic work-up in patients presenting with scapular winging, shoulder weakness or pain of unknown origin.