Dermatomal analgesia achieved with quadratus lumborum blocks is site-dependent and inconsistent. Cadaveric and clinical studies reveal multiple mechanisms of action. We dissected six fresh human cadavers bilaterally and thoroughly studied their neurological linkages to the quadratus lumborum muscle (QLM) to identify neural structures and block targets. At the end of the investigation, only the subcostal nerve (anterolateral) and the ilioinguinal nerves were found near the QLM in all specimens. The iliohypogastric nerve was found in only two specimens. No further neural targets were found in the fascial planes before and posterior to the QLM.
OBJECTIVES: Total Hip Arthroplasty (THA) may be a risky proposition in patients with comorbidities, and they may require systemic analgesics for chronic hip pain (CHP). Since traditional pain medications may not provide complete pain relief or carry prohibitive adverse effects, pulsed radiofrequency (PRF) treatment of the hip articular nerves (HAN) has been proposed for effective clinical outcomes. We determined the efficacy of PRF-HAN in improvement in CHP compared to baseline pain on conventional systemic analgesics. METHODS: Between August 2015 and December 2021, 31 adult patients with severe comorbid conditions and excruciating chronic hip pain were subjected to a PRF-HAN procedure following a diagnostic block. All 31 patients received PRF of the articular branches of the femoral and obturator nerves. Demographic parameters, numerical rating scale (NRS), Harris Hip Score (HHS), WOMAC scores, the change of these scores from baseline, and any adverse effects were recorded before treatment and on day 1, 1st week, 6 weeks, and 6 months after treatment. RESULTS: All the patients who underwent the PRF-HAN reported a significant improvement in NRS, HHS, and WOMAC scores compared to the baseline values on day 1, at the end of the 1st week, and the 6th week (p<0.001). No adverse events were documented in the study post-procedure until the end of 6 months. CONCLUSION: PRF-HAN is a strong alternative for chronic pain management and augments physical functioning and a return to daily activity in patients who would be deprived of arthroplasty considering associated comorbid conditions.
Chronic Pain , Radiofrequency Ablation , Adult , Humans , Femoral Nerve/surgery , Pain , Analgesics , Hip Joint/innervation , Treatment Outcome , Chronic Pain/therapy
BACKGROUND: Radiofrequency ablation of genicular nerves is recommended to ameliorate the pain of osteoarthritis of the knee. However, long-term efficacy in patients with persistent pain following total knee arthroplasty remains elusive. The current study aimed to evaluate radiofrequency ablation of genicular nerves using a hybrid technique to manage severe incapacitating pain and quality of life following surgery. METHODS: This prospective, observational study included patients suffering from intractable knee pain with scores > 4 on the Numeric rating scale after 6 months of total knee arthroplasty. Therapy included radiofrequency ablation of the superior medial, lateral, and inferior medial genicular nerves using a hybrid technique. The Numeric rating scale and Oxford Knee Score for quality of life were assessed before therapy and at 1-, 3- and 6 months following treatment. RESULTS: Average pain scores reduced from 8.4 ± 1.3 (admission) to 3.3 ± 1.4 (1 month; p= <0.001) but subsequently started to increase to 4 ± 1.2 (3 months; p = 0.58), and 5.6 ± 0.9 (6 months; p= <0.001). Average Oxford Knee Score significantly improved from 14.2 ± 5.9 (admission) to 38 ± 8.6(1 month); p= <0.001, but these too subsequently reduced to 36.4 ± 7.9 (3 months); p= 1, and 22.5 ± 12.5(6 months); p= <0.001. CONCLUSIONS: Ultrasound-guided radiofrequency ablation of genicular nerves diminishes intractable pain and disability in patients with chronic knee pain following total knee arthroplasty. Treatment is safe and effective, however, the benefit declined by 6 months. A repeat block would be necessary if the pain score worsens.
Knee Joint , Quality of Life , Humans , Prospective Studies , Nepal , Pain
Background: The erector spinae plane (ESP) block is the most sought-after block since its inception. However, it is more of dorsal rami block with unpredictable ventral diffusion to the paravertebral area. We injected dye in ESP and other paraspinal spaces to study and compare the dye diffusion pattern along the neuroaxis and paraspinal region in human cadavers. Methods: In six soft-embalmed cadavers (12 specimens), 20 mL methylene blue dye (erector spinae plane and paravertebral space) or indocyanine green dye (inter-ligament space) was injected bilaterally using an in-plane ultrasound-guided technique at the level of the costotransverse junction of fourth thoracic vertebrae. Dye spread was evaluated bilaterally in the coronal plane in the paravertebral and intercostal spaces from the 1st and the 12th rib. Axial and sagittal sections were performed at the level of the 4th thoracic vertebrae. After cross sections, the extent of dye spread was investigated in ESP, inter-ligament, and paravertebral spaces. The staining of the ventral and dorsal rami and spread into the intercostal spaces was evaluated. Results: ESP injection was mainly restricted dorsal to the costotransverse foramen and did not spread anteriorly to the paravertebral space. The paravertebral injection involved the origin of the spinal nerve and spread laterally to the intercostal space. The inter-ligament space injection showed an extensive anterior and posterior dye spread involving the ventral and dorsal rami. Conclusions: Following ESP injection, there was no spread of the dye anteriorly to the paravertebral space and it only involved the dorsal rami. Inter-ligamentous space injection appears to be the most promising block as dye spread both anteriorly to paravertebral space and posteriorly toward ESP.
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.
In this case series, we investigated the feasibility of combining ultrasound and neurostimulation for inserting a stimulating epidural catheter in the thoracic epidural space through the caudal route in neonates. Twelve neonates undergoing tracheo-oesophageal fistula repair under general anaesthesia were studied. The catheter was visible on ultrasound as a hyperechoic dot in the epidural space. Inadvertent high placement was identified in two neonates with neurostimulation, in whom the catheter was withdrawn to the thoracic epidural space, and the position was confirmed on ultrasound. A 0.5 ml/kg bolus dose of 0.125% bupivacaine injected through the epidural catheter was imaged in real-time in the epidural space. Block was effective in 10 neonates; two needed an additional local anaesthetic (LA) bolus. To conclude, ultrasound with neurostimulation facilitates accurate positioning of the caudally placed epidural catheter to the mid-thoracic level in neonates.
Abstract The paraspinal space is intriguing in nature. There are several needle tip placements described in compact anatomical spaces. This has led to an incertitude regarding the appropriate anatomic locations for needle tip positions. Through our cadaver models we try to resolve the issues surrounding needle tip positions clarifying anatomical spaces and barriers. Further we propose an anatomical classification based on our findings in cadaveric open dissections and cross and sagittal sections.
Nerve Block , Cadaver , Ultrasonography, Interventional , Needles
Lumbar erector spinae plane block (ESPB) is effective for spine surgeries but is deep and technically demanding. Sacral ESPB is a novel approach for sacrococcygeal procedures and can potentially cover lumbar dermatomes by the cranial drug spread. This is the first reported case series demonstrating the potential analgesic efficacy of sacral ESPB for lumbar spine surgeries. Five patients with radiculopathy at the lumbosacral area level were scheduled for transforaminal lumbar interbody fusion (TLIF). General anaesthesia was induced as per standard practice. All patients received sacral ESP in a prone position under ultrasound guidance with a needle inserted in-plane while targeting the fascial plane between the S2 median crest and overlying muscles. All the included patients had good analgesia in the postoperative period and required minimal opioid analgesic doses. Sacral ESPB is an easy, effective, and safe technique in the scheme of multimodal analgesia for TLIF surgeries as a component of pre-emptive analgesia, where the main goal is an opioid-sparing effect.
Background: The clinical outcomes (time to ambulation, length of stay, and home discharge) after proximal femoral nail (PFN) for proximal femoral fractures (PFF) is dependent on successful pain management. Currently, the lumbar erector spinae plane block (LESPB) is in vogue and is associated with favorable outcomes in the postoperative period. Our study aimed to evaluate whether a LESPB provided equivalent analgesia and clinical outcomes as compared to LPB in PFN for PFF. Material and Methods: We compared LPBs [L] with LESPBs [E], with 30 patients in each group, performed from June 2020 to June 2021 for PFN in PFF's. The primary outcome of this study was the average NRS pain scores over 24 hours postoperatively. Secondary outcomes included pain scores at different time points over 24 hours, opioid consumption between the groups at 24 hours postoperatively, time for request of first parenteral analgesia, quadriceps weakness and adverse events. Results: The average pain scores over 24 hours were better in the LESPB group as compared to the LPB group (p = 0.02). Further, only n = 5 (30%) of patients in the LESPB group required opioids, while n = 13 (43.333%) of patients in the LPB group required opioids. Moreover, the median time for request of first parenteral analgesia was 615 (480-975) minutes, weakness of quadriceps function occurred in 2 patients in the L group, which recovered at 3rd and 5th month, respectively, with no incidences of hemodynamic instability and respiratory complications. Conclusions: This trial demonstrated that single bolus LESPB is superior to LPB in terms of analgesic outcomes, has low adverse events, and is an agreeable substitute for patients with PFF undergoing a PFN.
We describe cases in which a preoperative computed tomography was used to guide the placement of an epidural catheter through the defect in the intervertebral foramina in patients with severe lumbar scoliosis. We demonstrate the adroitness with which epidural catheters were inserted through the intervertebral foramina. Computed tomography scan illustrates and plots the needle path creating a 3-dimensional image of the vertebral body rotation, needle trajectory, and the distance from the skin to the intervertebral foramina. Severe scoliosis is defined as a lateral curvature (Cobb's angle) of more than 50 degrees. It was proposed in severe idiopathic scoliosis that interventional pain management techniques are managed with fluoroscopic imaging or an alternative form. However, after a computed tomography evaluation of the scoliotic spine, we assumed that the intervertebral foraminal anatomy would facilitate a safe and efficient epidural needle and subsequent catheter positioning in severe scoliotic patients.
In five patient undergoing surgery for proximal humerus fracture we investigated into postoperative analgesia provided by continuous costoclavicular block using continuous stimulating catheter. The postoperative pain scores were less than 4 in all patients except in two patients who required intravenous tramadol 50 mg as a rescue analgesic. The radiocontrast dye study executed in two patients revealed contiguous contrast spread through the brachial plexus sheath with the catheter tip in the interscalene space. We propose that a continuous costoclavicular block with a retrograde stimulating catheter is a feasible alternative regional anesthesia technique for postoperative analgesia in shoulder surgery.
Analgesia , Brachial Plexus Block , Humans , Ropivacaine , Anesthetics, Local , Shoulder/surgery , Pain, Postoperative/drug therapy , Pain, Postoperative/prevention & control , Brachial Plexus Block/methods , Catheters , Ultrasonography, Interventional/methods
Abstract In five patient undergoing surgery for proximal humerus fracture we investigated into postoperative analgesia provided by continuous costoclavicular block using continuous stimulating catheter. The postoperative pain scores were less than 4 in all patients except in two patients who required intravenous tramadol 50 mg as a rescue analgesic. The radiocontrast dye study executed in two patients revealed contiguous contrast spread through the brachial plexus sheath with the catheter tip in the interscalene space. We propose that a continuous costoclavicular block with a retrograde stimulating catheter is a feasible alternative regional anesthesia technique for postoperative analgesia in shoulder surgery.
Humans , Brachial Plexus Block/methods , Analgesia , Pain, Postoperative/prevention & control , Pain, Postoperative/drug therapy , Shoulder/surgery , Ultrasonography, Interventional/methods , Catheters , Ropivacaine , Anesthetics, Local
The brachial plexus blocks (BPBs) are routinely performed for all surgeries in the vicinity of the elbow joint. Phrenic nerve paresis is a major problem with above-clavicle blocks especially the interscalene approach. The primary aim of this pilot study was to assess feasibility and to evaluate if perioperative pain management with the articular and cutaneous nerve block, the peri-humeral block (PHB) resulted in decreased use of opioid consumption in the intraoperative and postoperative period for the first 24 hours. Twenty-four patients with distal humerus fracture received ultrasound (US)-guided PHB as part of their perioperative anesthetic management. The primary aim was to evaluate block efficacy in terms of time to first analgesia and opioid consumption in first 24 hours. US in real time revealed that in all patients the local anesthetic was optimally deposited. Due to a stable intraoperative hemodynamics, none of the patients required additional opioid doses. The median pain scores over 24 hours were 2.4 with IQR (0-3.8). The mean time to first analgesic was 425.417 ± 229.005 min. There were no adverse effects reported at the time of hospital discharge. Though the US-guided PHB would not replace the BPB, in some special circumstances, it would be desirable to implement the former block which has opioid and motor sparing features and incorporate with multimodal analgesia.
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.
The paraspinal space is intriguing in nature. There are several needle tip placements described in compact anatomical spaces. This has led to an incertitude regarding the appropriate anatomic locations for needle tip positions. Through our cadaver models we try to resolve the issues surrounding needle tip positions clarifying anatomical spaces and barriers. Further we propose an anatomical classification based on our findings in cadaveric open dissections and cross and sagittal sections.
Nerve Block , Humans , Cadaver , Needles , Ultrasonography, Interventional
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.
Pain, Postoperative , Femur , Hip Fractures , Lumbosacral Plexus , Ultrasonography , Acute Pain , Anesthesia, Conduction
Background: Paraneural sheath engulfing the sciatic nerve (SN) between the ischial tuberosity and the greater trochanter is well known. Methods: In order to explore the anatomical planes separating the paraneurium from the epineurium in SN, we conducted a cadaveric study (two patients and four specimens), followed by a clinical study in 10 patients. Results: We demonstrated an elevation of 5-7 layers of paraneural tissues after an in-plane injection in the longitudinal axis of the proximal SN, which was possibly the last of the paraneural sheath. In the clinical study, the block provided low pain scores with no rescue analgesia postoperatively and no neurological deficit at the time of discharge. Conclusion: This is probably the first series which has described the elevation of several layers of paraneural tissues after an in-plane injection in the longitudinal axis of the proximal SN.
