Development and validation of metrics for assessment of ultrasound-guided fascial block skills☆.

BACKGROUND: As few anaesthetists provide lumbar erector spinae block for disc surgery, there is a need to provide training to enable a randomised controlled trial investigating analgesia after painful spinal surgery (NIHR153170). The primary objective of the study was to develop and measure the construct validity of a checklist for assessment of skills in performing lumbar and thoracic erector spinae fascial plane injection using soft-embalmed Thiel cadavers. METHODS: Twenty-four UK consultant regional anaesthetists completed two iterations of a Delphi questionnaire. The final checklist consisted of 11 steps conducive to best practice. Thereafter, we validated the checklist by comparing the performance of 12 experts with 12 novices, each performing lumbar and thoracic erector spinae plane injections or fascia iliaca, serrato-pectoral (PEC II) and serratus injections, randomly allocated to the left and right sides of six soft-embalmed Thiel cadavers. Six expert, trained raters blinded to operator and site of block examined 120 videos each. RESULTS: The mean (95% confidence interval) internal consistency of the 11-item checklist for erector spinae plane injection was 0.72 (0.63-0.79) and interclass correlation was 0.88 (0.82-0.93). The checklist showed construct validity for lumbar and thoracic erector spinae injection, experts vs novices {median (interquartile range [range]) 8.0 (7.0-10.0 [1-11]) vs 7.0 (5.0-9.0 [4-11]), difference 1.5 (1.0-2.5), P<0.001}. Global rating scales showed construct validity for lumbar and thoracic erector spinae injection, 28.0 (24.0-31.0 [7-35]) vs 21.0 (17.0-24.0 [7-35]), difference 7.5 (6.0-8.5), P<0.001. The most difficult items to perform were identifying the needle tip before advancing and always visualising the needle tip. Instrument handling and flow of procedure were the areas of greatest difficulty on the global rating scale (GRS). Checklists and GRS scores correlated. There was homogeneity of regression slopes controlling for status, type of injection, and rater. Generalisability analysis showed a high reliability using the checklist and GRS for all fascial plane blocks (Rho [ρ2] 0.93-0.96: Phi [ϕ] 0.84-0.87). CONCLUSIONS: An 11-point checklist developed through a modified Delphi process to provide best practice guidance for fascial plane injection showed construct validity in performing lumbar and thoracic erector spinae fascial plane injection in soft-embalmed Thiel cadavers.

Quantifying thoracolumbar fascia deformation to discriminate acute low back pain patients and healthy individuals using ultrasound.

Reduced shear strain and deformability of the thoracolumbar fascia has been linked to low back pain. A number of ultrasound examination methods have been developed for laboratory rather than clinical practice. The aim of this study was to examine the reliability and discriminative validity (patients vs. healthy individuals) of an ultrasound (US) measurement method for the quantification of thoracolumbar fascia deformation (TLFD). A cross-sectional study with US assessment and rater blinding was conducted in a manual therapy clinic and a university laboratory. 16 acute low back pain (aLBP) patients and 15 healthy individuals performed a standardized trunk extension task. US measurements of TLFD were carried out independently by two raters by imaging the TLF in the starting and ending positions of the movement. Intra-rater and inter-rater reliability were calculated using intraclass correlation coefficients (ICCs) and minimal detectable changes (MDC) were calculated. Receiver operating characteristic (ROC) curve analysis was used to determine the cut-off for TLFD to discriminate the study groups. Kappa statistics were performed to assess rater agreement in discrimination. Intra-rater reliability was excellent (ICC: .92, MDC: 5.54 mm, p < .001) and inter-rater reliability was good (ICC: .78, MDC: 8.70 mm, p < .001). The cut-off for TLFD was 6 mm with a sensitivity of 100% and a specificity of 93.75% and the raters agreed moderately (κ = 0.74, p < .001) when distinguishing patients and controls. The reliability of the US method for assessing TLFD is moderate to excellent, and the ability to discriminate aLBP patients from healthy individuals is moderate. The method could be used to capture an additional parameter in morphological aLBP screenings.

Ultrasonographic measurements of gastro-soleus fascia thickness in midportion Achilles tendinopathy: A case-control study.

BACKGROUND: The Achilles tendon is one of the thickest, largest, and strongest tendons in the human body. Biomechanically, the AT represents the conjoint tendon of the triceps surae muscle, placed in series with the plantar fascia (PF) to ensure force transmission from the triceps surae toward the toes during walking, running, and jumping. Commonly encountered in the diagnostic evaluation of heel pain, Achilles tendinopathy (AT) refers to a combination of pathological changes affecting the tendon itself often resulting from excessive repetitive stress and overuse. Nevertheless, increasing evidence demonstrates that structural alterations due to overuse or abnormal patterns of skeletal muscle activity are not necessarily restricted to the muscles or tendons but can also affect the fascial tissue. At the same time, there has been recent discussion regarding the role of the fascial tissue as a potential contributor to the pathophysiological mechanisms of the development of several musculoskeletal disorders including tendinopathies. To the best of our knowledge, ultrasound (US) imaging studies on the fascial structures related to the triceps surae complex, as well as their possible correlation with Achillodynia have never been presented in the current literature. METHODS: In the present study, a comparative US imaging evaluation of textural features of the suro-Achilleo-plantar complex was performed in 14 healthy controls and 14 symptomatic subjects complaining of midportion AT. The thickness of the Achilles tendon, paratenon, intermuscular fascia, and PF has been assessed with US. In addition, both groups underwent the Victorian Institute of Sport Assessment-Achilles (VISA-A), a disease-specific questionnaire that measures the severity of symptoms of AT. Correlations between quantitative ultrasound measures and VISA-A scores were determined through Pearson or Spearman's rho correlations. RESULTS: Our ultrasonographic findings revealed statistically significant differences (p<0.05) in Achilles tendon and paratenon thicknesses between AT patients and controls. No significant differences were observed between groups in PF at the calcaneal insertion as all mean measures were within the expected range of a normal PF on US imaging. In contrast, in tendinopathic subjects, the deep intermuscular fascia between medial gastrocnemius (MG) and soleus (SOL) muscles is significantly (p<0.01) and considerably thickened compared to those of healthy subjects. Moderate correlations exist between tendon and paratenon thicknesses (r= 0.54, p= 0.04) and between MG-SOL fascia and tendon thicknesses (r= 0.58, p= 0.03). Regarding symptom severity and US morphological findings, the Spearman ρ test showed no correlation. CONCLUSIONS: Our data demonstrate that, in symptomatic subjects, US alterations are not restricted to paratenon and intratendinous areas, but also affect upstream structures along the myofascial chain, resulting in thickening of the fascia interposed between MG and SOL muscles. Moreover, positive correlations were found between MG-SOL fascia thickening and abnormalities in AT, paratenon, and symptom severity. Thus, US alterations in the fascial system should be interpreted within the clinical context of patients with AT as they may in turn represent important predictors of subsequent clinical outcomes and could help healthcare professionals and clinicians to refine non-operative treatment strategies and rehabilitation protocols for this disease.

Sonographic measurement of deep fascia parameters - Interrater reliability.

PURPOSE: The deep fascia has recently been a current topic in many medical fields, including rehabilitation. Some research has already focused on assessing deep fascia, however results of individual authors differ in certain aspects. This study focuses on the inter-rater reliability of ultrasound (US) measurement of the thickness of deep fascia and loose connective tissue (LCT). The aim was to define the causes of any discrepancies in measurement that could contribute to the unification of management of evaluating fascia. METHODS: An observational study was performed including 20 healthy individuals in whom fascia lata of the anterior thigh was examined by US imaging and then measured in Image J software. Three raters participated in this study: the first with 6 years of US imaging experience, other two were newly trained. The measurement of fascial parameters was conducted in two phases with special consultation between them resulting in an agreement of the research team on the more precise way of measurement. RESULTS: Results revealed the value of inter-rater reliability ICC3,1 = 0.454 for deep fascia thickness and ICC3,1 = 0.265 for LCT thickness in the first phase and any significant difference in the second phase. This poor inter-rater reliability led to a search for possible causes of discrepancies, which authors subsequently highlighted. CONCLUSION: The findings of the study show the main pitfalls of deep fascia measurement that should contribute to the unification of evaluation.

Ultrasound Imaging of Thoracolumbar Fascia: A Systematic Review.

Over the past decade, there has been a notable increase in research focused on ultrasound imaging of thoracolumbar fascia (TLF). Nevertheless, published papers' results about the application of US imaging in TLF examination are still sparse. Background and Objevtives: Hence, this systematic review was performed aiming to firstly investigate the use and the methodology of ultrasound imaging to assess pathologic and healthy TLF. Secondarily, we aim to assess intra- and inter-observer reproducibility of US imaging in TLF assessment. Materials and Methods: The search was done on PubMed and Web of Science database from inception to April 2024. Furthermore, the references of included papers were thoroughly checked to find eligible publications. The MeSH keywords used were: "Thoracolumbar fascia", "Ultrasound Imaging", "Ultrasound", "Ultrasonography", and "Ultrasound examination". Results: Studies were aimed primarily at TLF diagnosis, treatment monitoring, or evaluating movement-related changes, underscoring the diverse clinical applications. The US parameters assessed included TLF thickness, echogenicity, stiffness, deformation, shear strain, and displacement, providing comprehensive insights into TLF features. Conclusions: Advanced US imaging holds promise as a reliable tool in musculoskeletal assessment, offering insights into TLF pathology/disfunction, treatment outcomes, and movement dynamics.

The Importance of Preconditioning for the Sonographic Assessment of Plantar Fascia Thickness and Shear Wave Velocity.

Plantar fasciopathy is a very common musculoskeletal complaint that leads to reduced physical activity and undermines the quality of life of patients. It is associated with changes in plantar fascia structure and biomechanics which are most often observed between the tissue's middle portion and the calcaneal insertion. Sonographic measurements of thickness and shear wave (SW) elastography are useful tools for detecting such changes and guide clinical decision making. However, their accuracy can be compromised by variability in the tissue's loading history. This study investigates the effect of loading history on plantar fascia measurements to conclude whether mitigation measures are needed for more accurate diagnosis. The plantar fasciae of 29 healthy participants were imaged at baseline and after different clinically relevant loading scenarios. The average (±standard deviation) SW velocity was 6.5 m/s (±1.5 m/s) and it significantly increased with loading. Indicatively, five minutes walking increased SW velocity by 14% (95% CI: -1.192, -0.298, t(27), p = 0.005). Thickness between the calcaneal insertion and the middle of the plantar fascia did not change with the tissues' loading history. These findings suggest that preconditioning protocols are crucial for accurate SW elastography assessments of plantar fasciae and have wider implications for the diagnosis and management of plantar fasciopathy.

Retroperitoneum revisited: a review of radiological literature and updated concept of retroperitoneal fascial anatomy with imaging features and correlating anatomy.

PURPOSE: Spread of disease in the retroperitoneum is dictated by the complex anatomy of retroperitoneal fasciae and is still incompletely understood. Conflicting reports have led to insufficient and incorrect anatomical concepts in radiological literature. METHODS: This review will discuss previous concepts prevalent in radiological literature and their shortcomings will be highlighted. New insights from recent anatomical and embryological research, together with imaging examples, will be used to clarify patterns of disease spread in the retroperitoneum that remain unexplained by these concepts. RESULTS: The fusion fascia and the renal fascia in particular give rise to planes and spaces that act as vectors for spread of disease in the retroperitoneum. Some of these planes and structures, such as the caudal extension of the renal fascia, have previously not been described in radiological literature. CONCLUSION: New insights, including the various fasciae, potential spaces and planes, are incorporated into an updated combined retroperitoneal fascial concept.

Short-term effects of 448 kilohertz radiofrequency stimulation on plantar fascia measured by quantitative ultrasound elastography and thermography on active healthy subjects: an open controlled clinical trial.

Objective: This study is an open clinical trial. The aim of this study was to show the changes that occur in the viscoelastic properties of the plantar fascia (twenty healthy volunteers) measured by SEL and the changes in the plantar fascia temperature measured by thermography after the application of a 448 kHz capacitive resistive monopolar radiofrequency (CRMR) in active healthy subjects immediately after treatment and at the 1-week follow-up.Methods: Furthermore, to analyze if an intervention with 448 kHz CRMR in the plantar fascia of the dominant lower limb produces a thermal response in the plantar fascia of the non-dominant lower limb. The final objective was to analyze the level of association between the viscoelastic properties of the PF and the temperature before and after the intervention with 448 kHz CRMR.Results: Our results showed that a temperature change, which was measured by thermography, occurred in the plantar fascia after a single intervention (T0-T1) and at the 1-week follow up (T1-T2).Conclusion: However, no changes were found in the viscoelastic properties of the plantar fascia after the intervention or at the 1-week follow up. This is the first study to investigate changes in both plantar fascia viscoelastic properties and in plantar fascia temperature after a radiofrequency intervention.

Predicting the response to neoadjuvant chemoradiation for rectal cancer using nomograms based on MRI tumour regression grade.

PURPOSE: This study aimed to develop nomograms that combine clinical factors and MRI tumour regression grade to predict the pathological response of mid-low locally advanced rectal cancer to neoadjuvant chemoradiotherapy. METHODS: The retrospective study included 204 patients who underwent neoadjuvant chemoradiotherapy and surgery between January 2013 and December 2021. Based on pathological tumour regression grade, patients were categorized into four groups: complete pathological response (pCR, n=45), non-complete pathological response (non-pCR; n=159), good pathological response (pGR, n=119), and non-good pathological response (non-pGR, n=85). The patients were divided into a training set and a validation set in a 7:3 ratio. Based on the results of univariate and multivariate analyses in the training set, two nomograms were respectively constructed to predict complete and good pathological responses. Subsequently, these predictive models underwent validation in the independent validation set. The prognostic performances of the models were evaluated using the area under the curve (AUC). RESULTS: The nomogram predicting complete pathological response incorporates tumour length, post-treatment mesorectal fascia involvement, white blood cell count, and MRI tumour regression grade. It yielded an AUC of 0.787 in the training set and 0.716 in the validation set, surpassing the performance of the model relying solely on MRI tumour regression grade (AUCs of 0.649 and 0.530, respectively). Similarly, the nomogram predicting good pathological response includes the distance of the tumour's lower border from the anal verge, post-treatment mesorectal fascia involvement, platelet/lymphocyte ratio, and MRI tumour regression grade. It achieved an AUC of 0.754 in the training set and 0.719 in the validation set, outperforming the model using MRI tumour regression grade alone (AUCs of 0.629 and 0.638, respectively). CONCLUSIONS: Nomograms combining MRI tumour regression grade with clinical factors may be useful for predicting pathological response of mid-low locally advanced rectal cancer to neoadjuvant chemoradiotherapy. The proposed models could be applied in clinical practice after validation in large samples.

Thoracolumbar Fascia and Lumbar Muscle Stiffness in Athletes with A History of Hamstring Injury.

The purpose of this study was to examine the differences in thoracolumbar fascia (TLF) and lumbar muscle modulus in individuals with and without hamstring injury using shear wave elastography (SWE). Thirteen male soccer players without a previous hamstring injury and eleven players with a history of hamstring injury performed passive and active (submaximal) knee flexion efforts from 0°, 45° and 90° angle of knee flexion as well as an active prone trunk extension test. The elastic modulus of the TLF, the erector spinae (ES) and the multifidus (MF) was measured using ultrasound SWE simultaneously with the surface electromyography (EMG) signal of the ES and MF. The TLF SWE modulus was significantly (p < 0.05) higher in the injured group (range: 29.86 ± 8.58 to 66.57 ± 11.71 kPa) than in the uninjured group (range: 17.47 ± 9.37 to 47.03 ± 16.04 kPa). The ES and MF modulus ranged from 14.97 ± 4.10 to 66.57 ± 11.71 kPa in the injured group and it was significantly (p < .05) greater compared to the uninjured group (range: 11.65 ± 5.99 to 40.49 ± 12.35 kPa). TLF modulus was greater than ES and MF modulus (p < 0.05). Active modulus was greater during the prone trunk extension test compared to the knee flexion tests and it was greater in the knee flexion test at 0° than at 90° (p < 0.05). The muscle EMG was greater in the injured compared to the uninjured group in the passive tests only (p < 0.05). SWE modulus of the TLF and ES and MF was greater in soccer players with previous hamstring injury than uninjured players. Further research could establish whether exercises that target the paraspinal muscles and the lumbar fascia can assist in preventing individuals with a history of hamstring injury from sustaining a new injury.

Comparison of conventional MRI analysis versus MRI-based radiomics to predict the circumferential margin resection involvement of rectal cancer.

BACKGROUND: To compare the application of conventional MRI analysis and MRI-based radiomics to identify the circumferential resection margin (CRM) status of rectal cancer (RC). METHODS: A cohort of 301 RC patients with 66 CRM invloved status and 235 CRM non-involved status were enrolled in this retrospective study between September 2017 and August 2022. Conventional MRI characteristics included gender, age, diameter, distance to anus, MRI-based T/N phase, CEA, and CA 19 - 9, then the relevant logistic model (Logistic-cMRI) was built. MRI-based radiomics of rectal cancer and mesorectal fascia were calculated after volume of interest segmentation, and the logistic model of rectal cancer radiomics (Logistic-rcRadio) and mesorectal fascia radiomics (Logistic-mfRadio) were constructed. And the combined nomogram (nomo-cMRI/rcRadio/mfRadio) containing conventional MRI characteristics, radiomics of rectal cancer and mesorectal fascia was developed. The receiver operator characteristic curve (ROC) was delineated and the area under curve (AUC) was calculated the efficiency of models. RESULTS: The AUC of Logistic-cMRI was 0.864 (95%CI, 0.820 to 0.901). The AUC of Logistic-rcRadio was 0.883 (95%CI, 0.832 to 0.928) in the training set and 0.725 (95%CI, 0.616 to 0.826) in the testing set. The AUCs of Logistic-mfRadio was 0.891 (95%CI, 0.838 to 0.936) in the training set and 0.820 (95%CI, 0.725 to 0.905) in the testing set. The AUCs of nomo-cMRI/rcRadio/mfRadio were the highest in both the training set of 0.942 (95%CI, 0.901 to 0.969) and the testing set of 0.909 (95%CI, 0.830 to 0.959). CONCLUSION: MRI-based radiomics of rectal cancer and mesorectal fascia showed similar efficacy in predicting the CRM status of RC. The combined nomogram performed better in assessment.

Ultrasound-guided suprainguinal fascia iliaca compartment block and early postoperative analgesia after total hip arthroplasty: a randomised controlled trial.

BACKGROUND: Hip replacement surgery can be painful; postoperative analgesia is crucial for comfort and to facilitate recovery. Regional anaesthesia can reduce pain and postoperative opioid requirements. The role of ultrasound-guided suprainguinal fascia iliaca block for analgesia after elective total hip arthroplasty is not well defined. This randomised trial evaluated its analgesic efficacy. METHODS: Consenting participants (134) scheduled for elective primary total hip arthroplasty under spinal anaesthesia were randomly allocated to receive ultrasound-guided fascia iliaca block with ropivacaine 0.5% or sham block with saline. The primary outcome was opioid consumption in the first 24 h after surgery. Additional outcomes included pain scores at 4, 8, 12, and 16 h, opioid-related side-effects (nausea, vomiting, pruritis), ability to perform physiotherapy on the first postoperative day, and physiotherapist-assessed quadriceps weakness. RESULTS: There were no significant differences in 24-h opioid consumption (block vs sham block, mean difference -3.2 mg oral morphine equivalent, 95% confidence interval -15.3 to 8.1 mg oral morphine equivalent, P=0.55) or any other prespecified outcomes. CONCLUSIONS: In patients undergoing primary total hip arthroplasty, ultrasound-guided suprainguinal fascia iliaca block with ropivacaine did not confer a significant opioid-sparing effect compared with sham block. There were no differences in other secondary outcomes including pain scores, opioid-related side-effects, or ability to perform physiotherapy on the first postoperative day. CLINICAL TRIAL REGISTRATION: www. CLINICALTRIALS: gov (NCT03069183).

The difference in the upper trapezius deep fascia slides between individuals with and without myofascial pain syndrome: A case-control study.

INTRODUCTION: MPS is a chronic disorder caused by myofascial trigger points, leading to pain and limited neck movements due to impacted fascia. Studies have reported reduced fascia slides in chronic low back pain, but limited fascia slides in MPS patients are still unreported. AIM: We determined differences in upper trapezius' deep fascia slides between MPS and non-MPS participants. METHODS: Between January-August 2019, participants from diverse work sectors were recruited in Manila. An expert physiotherapist diagnosed MPS, while non-MPS participants performed full painless cervical movements. Participants underwent upper trapezius deep fascia scans on both shoulders while performing six cervical movements. An HS1 Konica Minolta ultrasound recorded the data. Two blinded physiotherapists used Tracker 5.0 © 2018 to analyze videos and quantify deep fascia slides by measuring the distance between two x-axis points. The Multivariate analysis of variance (MANOVA) assessed deep fascia slide differences in six active cervical movements. Pillai's Trace, with a range of 0-1 and a p-value of <0.05, was set. Effect sizes in individuals with and without MPS were calculated using Hedges' g and Cohen's d. RESULTS: Of the 327 participants (136 non-MPS, 191 MPS), 101 MPS participants had shoulder pain for <1 year and 103 experienced unilateral pain. The study examined 3800 ultrasound videos but found no significant difference in deep fascia slides across cervical movements between MPS and non-MPS groups (Pillai's Trace = 0.004, p = 0.94). Minor differences in deep fascia displacement were observed, with small effect sizes (g = 0.02-0.08). CONCLUSION: A limited deep fascia slide does not characterize MPS participants from non-MPS participants.

Thoracolumbar fascia and chronic low back pain in idiopathic lumbar scoliosis: an ultrasonographic study.

PURPOSE: The role of thoracolumbar fascia (TLF) in the development of chronic low back pain (CLBP) has growing evidence in the literature. Although CLBP is reported in individuals with idiopathic scoliosis (IS), its relationship with the TLF has yet not been established. This study aims to evaluate the TLF and its relationship with CLBP in IS. METHODS: A total of 60 individuals were included in the study. They were divided into three groups as follows: painful scoliosis (n = 20, age: 17.1 ± 3.7 years, Cobb angle: 15-43°), non-painful scoliosis (n = 20, age: 16.4 ± 3.4 years, Cobb angle: 15-45°), and healthy group (n = 20, age: 16.4 ± 4.7 years). Pain was evaluated using the short form of the McGill Pain Questionnaire. TLF thickness was evaluated on the lumbar region using ultrasonography. Trunk range of motion was assessed using a universal goniometer, and flexibility was assessed with sit-and-reach test. RESULTS: The thickness of the right TLF was greatest in the painful group, followed by non-painful (p = 0.007) and healthy (p < 0.001) groups. The thickness of the left TLF in the non-painful and painful groups was greater compared to the healthy group (p < 0.001). In the painful group, right TLF thickness was negatively correlated with trunk flexion/extension (r = -0.540, p = 0.014/r = -0.514, p = 0.020) and left rotation (r = -0.499, p = 0.025) but positively correlated with pain (r = 0.562, p = 0.01). CONCLUSIONS: Thickening of the TLF was observed in IS, whereby, in the presence of CLBP, it was further intensified. We suggest considering fascial thickening as a potential contributing factor to both pain and limited motion in relevant patients.

The effects of static and dynamic stretching on deep fascia stiffness: a randomized, controlled cross-over study.

AIM: Previous stretching studies mostly investigated effects on the skeletal muscle but comprehensive explorations regarding the role of the connective tissue are scarce. Since the deep fascia has been demonstrated to be sensitive to mechanical tension, it was hypothesized that the fascia would also respond to stretching, contributing to enhanced range of motion (ROM). METHODS: Forty (40) recreationally active participants (male: n = 25, female: n = 15) were included in the randomized controlled cross-over trial and allocated to different groups performing 5 min static (STAT) or dynamic (DYN) plantar flexor stretching or control condition (CC) in a random order. Pre- and immediately post-intervention, muscle and fascia stiffness, as well as muscle and fascia thickness were measured using high-resolution ultrasound and strain elastography. ROM was assessed in the ankle joint via the knee to wall test (KtW) and goniometer. RESULTS: STAT reduced both, muscle and fascia stiffness (d = 0.78 and 0.42, p < 0.001, respectively), while DYN did not reduce stiffness compared to the control condition (p = 0.11-0.41). While both conditions showed significant increases in the KtW (d = 0.43-0.46, p = 0.02-0.04), no significant differences to the CC were observed for the isolated ROM testing (p = 0.09 and 0.77). There was a small correlation between fascia stiffness decreases and ROM increases (r = - 0.25, p = 0.006) but no association was found between muscle stiffness decreases and ROM increases (p = 0.13-0.40). CONCLUSION: Our study is the first to reveal stretch-induced changes in fascia stiffness. Changes of fascia`s but not muscle`s mechanical properties may contribute to increased ROM following stretching.

The minimum effective concentration (MEC90) of bupivacaine for an ultrasound-guided suprainguinal fascia iliaca compartment block for analgesia in knee surgery: a dose-finding study.

BACKGROUND: In recent years, the suprainguinal fascia iliaca compartment block (SFICB) has become more common in clinical practice. This assessor-blinded dose-finding study aimed to determine the minimum effective concentration (MEC90, MEC95) of bupivacaine for a single-injection SFICB in patients undergoing arthroscopic anterior cruciate ligament repair. METHODS: This prospective study was conducted at a tertiary hospital (postoperative recovery room and ward). The SFICB was performed as a postsurgical intervention after spinal anesthesia. Seventy patients were allocated using the biased-coin design up-and-down sequential method. The ultrasound-guided SFICB was performed using different bupivacaine concentrations, and standard multimodal analgesia was administered to all patients. Block success was defined as the absence of pain or presence of only tactile sensation during the pinprick test conducted on the anterior and lateral regions of the mid-thigh six hours postoperatively. RESULTS: According to isotonic regression and bootstrap CIs, the MEC90 value of bupivacaine for a successful SFICB was 0.123% (95% CI [0.098, 0.191]) and the MEC95 value was 0.188% (95% CI [0.113, 0.223]). CONCLUSIONS: Our study showed that the MEC90 and MEC95 values for bupivacaine administered via an SFICB for analgesia were 0.123% and 0.188%, respectively. One advantage of using lower concentrations of bupivacaine is the associated reduction in quadriceps weakness.

Ultrasound guided quadro-iliac plane block: another novel fascial plane block.

STUDY OBJECTIVE: We report a novel block technique aimed to provide lumbosacral, abdominal, and hip analgesia: The quadro-iliac plane (QIP) block. DESIGN: A cadaveric examination that evaluates the spread of QIP block. SETTING: Cadaver laboratory. PATIENTS: One unembalmed cadaver. INTERVENTIONS: Bilateral ultrasound-guided QIP blocks on cadavers with 40 mL of methylene blue %0.5 each side. MEASUREMENTS: Dye spread in cadaver. MAIN RESULTS: There was staining in the deep interfascial plane of the erector spinae muscles. Extensive staining of the interfascial plane corresponding to the posterior aspect of the quadratus lumborum muscle (QLM) was observed. There was extensive staining on the anterior surface of the QLM. There was spread of dye traversing along the transversalis fascia and significantly infiltrating retroperitoneal fat tissue. Bilateral staining of the ilioinguinal and iliohypogastric nerves was observed. On the right, there was minimal staining over the subcostal nerve. There was dye present bilaterally within the deep regions of the transverse processes. The lumbar plexus was stained on both sides. CONCLUSION: The local anesthetic applied from a place where the QLM reaches its largest volume and the fascial plane creates a closed gap in the caudal area may exhibit a more rounded and extensive spread.Quadro-iliac plane block, involves the administration of local anesthetic to the posterior aspect of the QLM at its origin from the iliac crest. According to our cadaver study, this technique may be a promising option for alleviating acute and chronic pain in the lumbosacral, lower abdominal, and hip regions.

Anatomic evaluation to compare the dye spread with ultrasound-guided pericapsular nerve group (PENG) injection with or without an additional suprainguinal fascia iliaca (SIFI) injection in soft embalmed cadavers.

BACKGROUND: Novel interfascial plane blocks like PEricapsular Nerve Group (PENG) and SupraInguinal Fascia Iliaca (SIFI) blocks are effective for management of hip fracture pain. We compared the difference in the distribution of the dye injected and nerves stained by the addition of the SIFI block to the PENG block. METHODS: A total of 24 designated dye injections were performed in eight soft-embalmed cadavers. Under ultrasound guidance 20 ml green ink injected bilaterally in PENG block and 30 ml methylene blue dye was injected in the SIFI block on the right side. The cadavers were dissected 24 h later to assess the extent of dye spread. RESULTS: Extensive spread of dyes was seen on both side of iliacus muscle on the right side, but blue dye was not visible medial to the psoas tendon. The subcostal and iliohypogastric nerves were stained green in the infra-inguinal region. On the left side (PENG alone), the anterior division of the obturator, femoral and saphenous nerve (7/8) and iliohypogastric nerves (3/8) were stained in the infrainguinal region. In the suprainguinal region, the femoral nerve (5/8), accessory obturator nerve (3/8), lateral femoral cutaneous (1/8) and nerve to rectus femoris (4/8) were stained. The main obturator nerve trunk was spared with both injections while its anterior branch and accessory obturator nerve were stained with the PENG injection. CONCLUSION: The study findings indicate that combined PENG + SIFI injections lead to an extensive craniocaudal and longitudinal spread along the iliacus muscle. We perceive that the combination of these two injections will have a superior clinical outcome.

Development and validation of an assessment tool for adult simulated ultrasound-guided fascia iliaca block: a prospective monocentric study.

BACKGROUND: Fascia iliaca block (FIB) is an effective technique for analgesia. While FIB using ultrasound is preferred, there is no current standardised training technique or assessment scale. We aimed to create a valid and reliable tool to assess ultrasound-guided FIB. METHOD: This prospective observational study was conducted in the ABS-Lab simulation centre, University of Poitiers, France between 26-29 October and 14-17 December 2021. Psychometric testing included validity analysis and reliability between two independent observers. Content validity was established using the Delphi method. Three rounds of feedback were required to reach consensus. To validate the scale, 26 residents and 24 emergency physicians performed a simulated FIB on SIMLIFE, a simulator using a pulsated, revascularised and reventilated cadaver. Validity was tested using Cronbach's α coefficient for internal consistency. Comparative and Spearman's correlation analysis was performed to determine whether the scale discriminated by learner experience with FIB and professional status. Reliability was analysed using the intraclass correlation (ICC) coefficient and a correlation score using linear regression (R2). RESULTS: The final 30-item scale had 8 parts scoring 30 points: patient positioning, preparation of aseptic and tools, anatomical and ultrasound identification, local anaesthesia, needle insertion, injection, final ultrasound control and signs of local anaesthetic systemic toxicity. Psychometric characteristics were as follows: Cronbach's α was 0.83, ICC was 0.96 and R2 was 0.91. The performance score was significantly higher for learners with FIB experience compared with those without experience: 26.5 (22.0; 29.0) vs 22.5 (16.0; 26.0), respectively (p=0.02). There was a significant difference between emergency residents' and emergency physicians' scores: 20.5 (17.0; 25.0) vs 27.0 (26.0; 29.0), respectively (p=0.0001). The performance was correlated with clinical experience (Rho=0.858, p<0.0001). CONCLUSION: This assessment scale was found to be valid, reliable and able to identify different levels of experience with ultrasound-guided FIB.