Ultrasound-guided fascial plane blocks for post-breast surgery pain syndrome.

INTRODUCTION: Persistent pain following breast surgery is common and may be challenging to treat. In patients refractory to conservative treatments, ultrasound-guided fascial plane blocks of thoracic nerves can be a useful option. RESULTS: This type of neuro blockade technique provides advantages in terms of safety and efficacy that are convenient for physicians managing refractory and complex cases of post-breast surgery syndrome. CONCLUSION: This technical review aims to present an up-to-date summary of the most common ultrasound-guided fascial plane blocks for chronic pain in post-breast surgery patients, provide a detailed technical description of each intervention, and propose preferred injections based on the anatomical location of the pain.

Ultrasound-guided costovertebral joint injection-technique description and fluoroscopy and computerized tomography combined controlled cadaveric feasibility study.

OBJECTIVES: To describe and assess the feasibility of an ultrasound-guided technique for intra-articular injection of the costovertebral joints, in an unembalmed cadaveric specimen, utilizing fluoroscopy and cone beam computerized tomography for confirmation of contrast spread and needle tip position, respectively. METHODOLOGY: A single unembalmed cadaveric specimen was obtained. A single interventionist performed the placement of the needles under ultrasound guidance. Contrast dye was then injected through each of the needles under real-time fluoroscopy. Finally, the specimen was submitted to a cone beam computerized tomography with 3-dimensional acquisition and multiplanar reformatting to assess final needle tip position relative to the costovertebral joints. RESULTS: In total, 18 spinal needles were placed under ultrasound guidance. Fluoroscopy showed 4 distinct patterns of contrast spread: intra-articular in the costovertebral joint (13 levels in total), epidural (1 level), intra-articular in the facet joint of the target level (3 levels), and undetermined (1 level). Cone-beam computerized tomography confirmed 13 out of 18 needles to be adequately placed in the costovertebral joints (72% of the total) and 5 out of the 18 needles to be misplaced: 3 needles were placed in the facet joint of the target level, and 2 needles were placed in the epidural space. CONCLUSIONS: This study suggests that, when performed by experienced interventionists, this technique has an accuracy rate of 72%. Further studies are warranted before these results can be extrapolated to daily clinical practice.

Ultrasound-guided procedures for the management of chronic thoracic back pain: a technical review.

Pain arising from the thoracic region has been reported to be potentially as debilitating as cervical or lumbar back pain, and may stem from a vast number of spinal sources, including zygapophysial, costovertebral and costotransverse joints, intervertebral discs, ligaments, fascia, muscles, and nerve roots. Over the last two decades, the use of ultrasound in interventional spinal procedures has been rapidly evolving, due to the ultrasound capabilities of visualizing soft tissues, including muscle layers, pleura, nerves, and blood vessels, allowing for real-time needle tracking, while also reducing radiation exposure to both patient and physician, when compared to traditional fluoroscopy guidance. However, its limitations still preclude it from being the imaging modality of choice for some thoracic spinal procedures, notably epidural (interlaminar and transforaminal approaches) and intradiscal injections. In this technical review, we provide an overview of five thoracic spinal injections that are amenable to ultrasound guidance. We start by discussing their clinical utility, followed by the relevant topographic anatomy, and then provide an illustrated technical description of each of the procedures discussed: (1) erector spinae plane block; (2) intra-articular thoracic zygapophyseal (facet) joint injection; (3) thoracic medial branch block; (4) costotransverse joint injection; and (5) costovertebral joint injection.

Ultrasound-Guided Percutaneous Peripheral Nerve Stimulation of the Musculocutaneous Nerve for Refractory Antecubital ElbowPain-Brief Technical Report and Illustrative Case Report.

Chronic pain following distal biceps rupture (DBR) is often nonspecific in that it may arise due to the injury, subsequent surgical repair, or a combination of factors, making the painful symptoms challenging to treat. Peripheral nerve injury in the setting of DBR most commonly affects the musculocutaneous nerve or one of its terminal branches and may lead to chronic neuropathic pain involving the elbow and lateral/radial aspect of the forearm. In this brief technical report, we describe an ultrasound-guided (USG) technique for percutaneous implantation of a peripheral nerve stimulator (PNS) targeting the musculocutaneous nerve, along with an illustrative case report of successful treatment of chronic refractory pain following DBR utilizing this technique. Six months postimplantation, the patient reported a greater than 60% baseline pain intensity reduction, and no complications were noted.

La douleur chronique consécutive à une rupture distale du biceps est souvent non spécifique en ce sens qu'elle peut survenir en raison de la blessure, de la réparation chirurgicale ultérieure, ou d'une combinaison de facteurs, rendant les symptômes douloureux difficiles à traiter. La lésion du nerf périphérique dans le cadre d'une rupture distale du biceps affecte le plus souvent le nerf musculo-cutané ou l'une de ses branches terminales et peut entraîner des douleurs neuropathiques chroniques au niveau du coude et de la face latérale/radiale de l'avant-bras. Dans ce bref rapport technique, nous décrivons une technique guidée par ultrason pour l'implantation percutanée d'un stimulateur nerveux périphérique ciblant le nerf musculo-cutané, ainsi qu'un rapport de cas illustratif du traitement réussi de la douleur réfractaire suite à une rupture distale du biceps en utilisant cette technique. Six mois après l'implantation, le patient a signalé une réduction de plus de 60 % de l'intensité de la douleur initiale, et aucune complication n'a été observée.

Ultrasound-guided percutaneous peripheral nerve stimulation for chronic refractory neuropathic pain: a unique series.

During the last two decades, with the advent of recent technology, peripheral nerve stimulation has become an appealing modality at the forefront of pain management. In this case series, we document the clinical rationale and technical considerations on three of the most challenging cases, refractory to previous interventions, that were treated by our team with an ultrasound-guided percutaneous peripheral nerve stimulator targeting the musculocutaneous, bilateral greater occipital and subcostal nerves. At the 6-month follow-up, all patients experienced greater than 50% relief of baseline pain, with a near-complete resolution of pain exacerbations. Furthermore, to our knowledge, this is the first report of an ultrasound-guided percutaneous technique of a peripheral nerve stimulator targeting the musculocutaneous and subcostal nerves.

Peripheral nerve stimulation is a new tool used in the treatment of peripheral nerve pain. In this study, we share our experience using this technology in three unusual, difficult-to-treat chronic nerve pain presentations, targeting the musculocutaneous, bilateral greater occipital and subcostal nerves. All patients were asked about how pain levels had changed since the peripheral nerve stimulation device had been implanted. In every case, patients reported a decline in their pain level from day one. After 6 months of peripheral nerve stimulator use, all patients reported a greater than 50% pain relief.

A case for ultrasound-guided peripheral nerve stimulation in intractable anterior cutaneous nerve entrapment syndrome.

Aim: This case report documents the use of peripheral nerve stimulation in the setting of entrapment of the anterior cutaneous branches of the intercostal nerves, with pain rated by the patient as severe during exacerbation episodes. Materials & methods: Under ultrasound guidance, two permanent leads were implanted caudad to cephalad, along and superficial to the lateral aspect of the rectus abdominis, distal to the umbilicus (1 lead per side). Results: At the 6 month follow-up, the patient reported near complete resolution of baseline pain, as well as fewer, sporadic pain exacerbation episodes, rated as mild-to-moderate. Conclusion: This case report suggests that peripheral nerve stimulation might be a valuable treatment option for previously intractable abdominal pain due to entrapment of the anterior cutaneous branches.

Anterior cutaneous nerve entrapment syndrome is a peculiar, a largely disregarded pain condition. Current management algorithms rely mostly on local injections followed by surgical anterior neurectomy. This case report presents a case of longstanding, anterior cutaneous nerve entrapment syndrome, unresponsive to first-line treatment, that was successfully treated with peripheral nerve stimulation technology targeting the anterior cutaneous branches.

Ultrasound-guided hydrodissection of the superficial peroneal nerve for chronic neuropathic pain: a war veteran's story.

Aim: This case report presents the application of ultrasound-guided hydrodissection of the superficial peroneal nerve to treat chronic refractory neuropathic pain, rated by the patient with an average intensity of 6/10 on the numerical rating scale. Materials & methods: Under ultrasound guidance, the nerve was identified compressed by a herniation of the peroneus brevis. An in-plane hydrodissection was performed using a solution of 10 ml of ropivacaine and methylprednisolone until the epineurium was entirely separated from the surrounding tissue. Results: At the 2-month follow-up, the patient reported a decrease of pain, which he rated a 2/10 on the numerical rating scale. At this point, night-time episodes of moderate pain persisted. The procedure was repeated and at the 6-month follow-up, the patient remained pain free. Conclusion: This case report suggests that consecutive ultrasound-guided hydrodissection techniques might be a valuable option in the treatment of superficial peroneal nerve entrapment neuropathy.

Peripheral neuropathic pain is a debilitating pain condition. Management can be challenging and clinicians often rely on oral medications and surgical options. This case report presents the treatment of a case of longstanding, moderate-to-severe superficial peroneal nerve entrapment neuropathy due to a grenade explosion, with consecutive nerve hydrodissection using a solution containing an anesthetic and a corticosteroid. Immediately after the second procedure and at the 6-month follow-up the patient reported near-total relief.