Real-Time Ultrasound-Guided Spinal Injection Using a Transverse In-Plane Dependent Technique: A Case Series.

Ultrasound-guided (USG) spinal injection is generally performed using a paramedian sagittal oblique scan, with the patient in the lateral decubitus position, and the spinal needle inserted in-plane from the nondependent side. This report evaluated the feasibility of performing USG spinal injection, using an alternative transverse interspinous scan with in-plane needle insertion, a transverse in-plane dependent (TIPD) technique, in 30 adult patients undergoing elective surgery under spinal anesthesia. Dural puncture was successfully achieved in 29 of 30 (96.6%) patients with 2 (1-3) attempts in 5 (4-8) minutes using the TIPD technique. Multiple interspinous osteophytes accounted for technical failure in 1 patient.

High-definition ultrasound imaging defines the paraneural sheath and fascial compartments surrounding the cords of the brachial plexus at the costoclavicular space and lateral infraclavicular fossa.

BACKGROUND AND OBJECTIVES: The paraneural sheath is a multilayered network of collagen fibers that surround the brachial plexus. Currently, there are no sonographic data on the paraneural sheath of the brachial plexus, which this study aimed to evaluate. METHODS: Ultrasound imaging datasets of 100 patients who received a costoclavicular brachial plexus block, using high-definition ultrasound imaging, were retrospectively reviewed. Video files, representing sonograms before and after the local anesthetic injection, from the costoclavicular space and lateral infraclavicular fossa were collated and reviewed by three experienced anesthesiologists. Frequency (yes/no) of ultrasound visualization of the paraneural sheath, septum, and the anterior and posterior compartments was assessed. Representative sonograms from the costoclavicular space and lateral infraclavicular fossa were visually correlated with archived cadaver microanatomic sections from the same location. RESULTS: Datasets of the 98 patients who achieved surgical anesthesia were evaluated. The paraneural sheath, septum, and the anterior and posterior compartments were visualized in 17.3%, 7.1%, 5.1% and 5.1%, respectively, at the costoclavicular space before the brachial plexus block; this contrasts (p<0.001) with their visibility post-block (94.9%, 75.5%, 75.5% and 75.5%, respectively). At the lateral infraclavicular fossa, the corresponding visibility of these structures post-block were 67.7%, 81.5%, 81.5% and 81.5%, respectively. Ultrasound images of the paraneural sheath and septum correlated well with that in the cadaver microanatomic sections. CONCLUSION: We have demonstrated the paraneural sheath and fascial compartments surrounding the cords of the brachial plexus at the costoclavicular space and lateral infraclavicular fossa using high-definition ultrasound imaging. TRIAL REGISTRATION NUMBER: ClinicalTrials.gov Registry (NCT04370184), (https://www.clinicaltrials.gov/).

Ultrasound-guided subparaneural popliteal sciatic nerve block: there is more to it than meets the eyes.

The popliteal sciatic nerve block is routinely used for anesthesia and analgesia during foot and ankle surgery. This article reviews our current understanding of the anatomy of the sciatic nerve and discusses how fascial tissue layers associated with the nerve may affect block outcomes . The anatomy of the sciatic nerve is more complex than previously described. The tibial and common peroneal nerves within the sciatic nerve trunk appear to be centrally separated by the Compton-Cruveilhier septum and encompassed by their own paraneural sheaths. This unique internal architecture of the sciatic nerve appears to promote proximal spread of local anesthetic to the internal aspect of the sciatic nerve trunk after a subparaneural injection at or below the divergence of the tibial and common peroneal nerves.

Dry spinal tap during real-time ultrasound-guided paramedian spinal injection with patient in the lateral decubitus position: A single-centre retrospective study.

BACKGROUND: Real-time ultrasound-guided (USG) spinal injection is generally performed via the paramedian sagittal oblique (PMSO) ultrasound window. OBJECTIVE: The aim of this retrospective study was to draw attention to the occurrence of 'dry tap' during real-time USG spinal injection. DESIGN: Single-centre retrospective study. SETTING: University teaching hospital, Hong Kong, China. PATIENTS: Data from 113 patients (aged 69.2 ±â€Š18.0 years and BMI 22.3 ±â€Š3.6 kg m-2) of American Society of Anesthesiologists physical status 1 to 3 scheduled for surgery under neuraxial blockade between 2007 to 2017 were reviewed. INTERVENTIONS: Real-time USG spinal injections or combined spinal-epidural (CSE) using the PMSO ultrasound window with the patient in the lateral decubitus position and the spinal needle inserted from the nondependent side were studied. MAIN OUTCOME MEASURES: 'Dry tap' was defined as a failure of cerebrospinal fluid (CSF) to efflux from the hub of the needle, within 3 min, with the spinal needle visualised sonographically within the thecal sac. 'Slow CSF efflux' was defined as efflux of CSF within 1 to 3 min. Irrespective of whether it was a 'dry tap' or 'slow CSF efflux', the planned dose of local anaesthetic was injected through the spinal needle. RESULTS: The combined incidence of 'dry tap' and 'slow CSF efflux' was 23.8% (27/113) with an individual incidence for each event of 9.7% (11/113) and 14.2% (16/113), respectively. Under the conditions of this study, successful spinal anaesthesia developed in all patients. CONCLUSION: 'Dry tap' occurs in 9.7% of cases during real-time USG spinal injection using the PMSO ultrasound window, with the patient in the lateral decubitus position and the spinal needle inserted from the nondependent side. TRIAL REGISTRATION: ChiCTR-IOR-1800019011, Chinese Clinical Trials Registry (www.chictr.org.cn).

Ultrasound-Guided Selective Trunk Block to Produce Surgical Anesthesia of the Whole Upper Extremity: A Case Report.

None of the classical brachial plexus block techniques can reliably produce surgical anesthesia of the whole upper extremity that is from shoulder to hand. We describe ultrasound-guided "selective trunk block" (SeTB) that was successfully used to produce surgical anesthesia of the whole ipsilateral upper extremity in a patient undergoing intramedullary nailing of the humerus for a pathological fracture. The 3 trunks of the brachial plexus were individually identified and selectively blocked with 2 separate injections. We conclude that SeTB is a viable option when surgical anesthesia of the whole upper extremity, except for the intercostobrachial nerve (T2) territory, is being considered.

High definition ultrasound imaging of the individual elements of the brachial plexus above the clavicle.

BACKGROUND AND OBJECTIVES: Ultrasonography of the brachial plexus (BP) has been described but there are limited data on visualization of the T1 ventral ramus and the inferior trunk. This prospective observational study aimed to evaluate a high definition ultrasound imaging technique to systematically identify the individual elements of the BP above the clavicle. METHODS: Five healthy young volunteers underwent high definition ultrasound imaging of the BP above the clavicle. The ultrasound scan sequence (transverse oblique scan) commenced at the supraclavicular fossa after which the transducer was slowly swept cranially to the upper part of the interscalene groove and then in the reverse direction to the supraclavicular fossa. The unique sonomorphology of the C7 transverse process was used as the key anatomic landmark to identify the individual elements of the BP in the recorded sonograms. RESULTS: The neural elements of the BP that were identified in all volunteers included the ventral rami of C5-T1, the three trunks, divisions of the superior trunk, and formation of the inferior trunk (C8-T1). The C6 ventral ramus exhibited echogenic internal septation with a split (bifid) appearance in four of the five volunteers. In three of the four volunteers with a bifid C6 ventral ramus, the C7 ventral ramus was also bifid. CONCLUSION: We have demonstrated that it is feasible to accurately identify majority of the main components of the BP above the clavicle, including the T1 ventral ramus and the formation of the inferior trunk, using high definition ultrasound imaging. TRIAL REGISTRATION NUMBER: ChiCTR1900021749.

The Effect of a Single Dose Dexamethasone on Postoperative Pain in Patients Undergoing Gynecological Laparotomy Surgery.

Background: Acute postoperative pain is associated with many undesirable outcomes. Opioids are the mainstay for pain relief but their common side effects are still problematic. Many adjunctive agents such as NSAIDs and gabapentin have already been proved to be effective as multimodal analgesia. Dexamethasone has been reported to reduce postoperative nausea and vomiting but the analgesic effect is not well defined especially in open abdominal surgery. Objective: To evaluate efficacy of a single perioperative dose of dexamethasone on postoperative pain in gynecological laparotomy surgery. Material and Method: A prospective, randomized, double-blinded study was approved by the Institutional Review Board and registered with the Thai Clinical Trials Registry as TCTR20151116001. Fifty-two patients scheduled for elective gynecological laparotomy surgery were enrolled in the present study. Patients were randomized into two groups based on computer generated random number list. After induction, group D received intravenous dexamethasone 8 mg and group P received saline. Both groups were anesthetized in a standardized manner. Postoperative pain was managed with intravenous morphine using patient controlled analgesia. The primary outcome was total morphine consumption evaluated at 6- and 24-hour postoperatively. Pain score, nausea, and vomiting, shivering, sore throat, and adverse effects of dexamethasone were also recorded. Results: The total dose of morphine (0 to 24 hour after surgery) was less in D group (15.88±9.59 mg) compared with P group (24.25±15.26 mg) (p = 0.027). The doses during hour 0 to 6 were smaller in D group (11.28±6.66 mg) than the placebo (15.79±12.50) (p = 0.435). The numerical rating scale for pain at rest did not differ in both study groups, but pain in motion was less in D group than P group at 6-hour (p = 0.03) and 24-hour (p = 0.039) after surgery. No adverse effect was observed in both groups. Conclusion: A single perioperative dose 8 mg of dexamethasone is safe and significantly reduces pain at movement and morphine consumption in 24 hours after gynecological laparotomy surgery.