Feasibility and Analgesic Efficacy of Thoracolumbar Dorsal Ramus Nerve Block Using Multiorifice Pain Catheters for Scoliosis Surgery: A Prospective Cohort Study.

BACKGROUND: Approximately 38,000 scoliosis surgery correction operations are performed annually in the United States; these operations are associated with considerable postoperative pain which can be difficult to manage. This is largely attributed to an incision spanning multiple vertebral segments with paraspinal muscle dissection and retraction to facilitate the implantation of segmental hardware and rods. Frequently utilized analgesic modalities include intravenous patient-controlled analgesia and epidural analgesia, often in combination. We sought to ascertain the feasibility and analgesic efficacy of continuous thoracolumbar dorsal ramus nerve (TDRN) block using surgically placed multiorifice catheters. METHODS: Forty-two patients diagnosed with idiopathic scoliosis who underwent a posterior spinal fusion (PSF) were enrolled after consent was obtained. Patients were managed utilizing a standardized Enhanced Recovery After Surgery) protocol including a perioperative opioid-sparing regimen. Data were collected at specified time intervals during the recovery period. These data points included pain scores using the Numeric Rating Scale. Parenteral or both oral and parenteral opioid consumption doses were also collected every 4 hours. Any significant postoperative adverse events were recorded as well. RESULTS: A total of 42 patients had surgically placed TDRN catheters, and 40 patients were included in this study. The patients all reported low to moderate pain scores with low opioid consumption postoperatively, while the TDRN catheter delivery of local anesthetic analgesics did not result in significant complications. CLINICAL RELEVANCE: A regional technique utilizing TDRN catheters could be a valuable component of the postoperative pain management protocols for PSF surgery, and additional studies are warranted. CONCLUSION: This study evaluated the feasibility and analgesic efficacy of TDRN catheters for postoperative pain control following multilevel PSF for idiopathic scoliosis. Continuous local anesthetic delivery through TDRN catheters is a feasible and safe technique for postoperative pain control in these patients. Selective blockade of the dorsal rami might have benefits over epidural analgesia or other regional techniques.

Multimodal Acute Pain Management in the Parturient with Opioid Use Disorder: A Review.

The opioid epidemic in the United States has led to an increasing number of pregnant patients with opioid use disorder (OUD) presenting to obstetric units. Caring for this complex patient population requires an interdisciplinary approach involving obstetricians, anesthesiologists, addiction medicine physicians, psychiatrists, and social workers. The management of acute pain in the parturient with OUD can be challenging due to several factors, including respiratory depression, opioid tolerance, and opioid-induced hyperalgesia. Patients with a history of OUD can present in one of three categories: 1) those with untreated OUD; 2) those who are currently abstinent from opioids; 3) those being treated with medications to prevent withdrawal. A patient-centered, multimodal approach is essential for optimal peripartum pain relief and prevention of adverse maternal and neonatal outcomes. Medications for opioid use disorder (MOUD), previously referred to as medication-assisted therapy (MAT), include opioids like methadone, buprenorphine, and naltrexone. These are prescribed for pregnant patients with OUD, but appropriate dosing and administration of these medications are critical to avoid withdrawal in the mother. Non-opioid analgesics such as acetaminophen and nonsteroidal anti-inflammatory drugs (NSAIDs) can be used in a stepwise approach, and regional techniques like neuraxial anesthesia and truncal blocks offer opioid-sparing options. Other medications like ketamine, clonidine, dexmedetomidine, nitrous oxide, and gabapentinoids show promise for pain management but require further research. Overall, a comprehensive pain management strategy is essential to ensure the well-being of both the mother and the fetus in pregnant patients with OUD.

Ultrasound-Guided Cervical Cervicis Plane Block for Postoperative Pain Control in Cervical Spine Surgery: A Technical Note.

BACKGROUND: New peripheral nerve blocks targeting the dorsal rami are possible for postoperative analgesia in patients undergoing posterior cervical spine surgeries. A cervical cervicis plane (CCeP) block can be performed under ultrasound guidance. We provide a description of this nerve block and ultrasound imaging with relevant sonographic structures. METHODS: Sonographic imaging from 2 spine surgeries showed CCeP blocks at the upper and lower cervical levels. RESULTS: A CCeP block targets the fascial plane between the semispinalis cervicis muscle and the semispinalis capitis muscle because the CCeP is a continuous plane from occiput to C7, which contains the dorsal rami of the cervical spinal nerves. The deep cervical artery can always be identified under ultrasound in this plane. CONCLUSIONS: The CCeP block is an easy nerve block to perform under ultrasound guidance to block the dorsal rami of the cervical nerves. It can provide effective analgesic effects for patients undergoing upper and lower posterior cervical spine surgery without compromising neurophysiology monitoring.

Veno-Arterial Extracorporeal Membrane Oxygenation Rescue in a Patient With Pulmonary Hypertension Presenting for Revision Total Hip Arthroplasty: A Case Report and Narrative Review.

Patients with pulmonary hypertension (PH) are at an increased risk of perioperative morbidity and mortality when undergoing non-cardiac surgery. We present a case of a 57-year-old patient with severe PH, who developed cardiac arrest as the result of right heart failure, undergoing a revision total hip arthroplasty under combined spinal epidural anesthesia. Emergent veno-arterial (VA) extracorporeal membrane oxygenation (ECMO) was undertaken as rescue therapy during the pulmonary hypertensive crisis and a temporizing measure to provide circulatory support in an intensive care unit (ICU). We present a narrative review on perioperative management for patients with PH undergoing non-cardiac surgery. The review goes through the updated hemodynamic definition, clinical classification of PH, perioperative morbidity, and mortality associated with PH in non-cardiac surgery. Pre-operative assessment evaluates the type of surgery, the severity of PH, and comorbidities. General anesthesia (GA) is discussed in detail for patients with PH regarding the benefits of and unsubstantiated arguments against GA in non-cardiac surgery. The literature on risks and benefits of regional anesthesia (RA) in terms of neuraxial, deep plexus, and peripheral nerve block with or without sedation in patients with PH undergoing non-cardiac surgery is reviewed. The choice of anesthesia technique depends on the type of surgery, right ventricle (RV) function, pulmonary artery (PA) pressure, and comorbidities. Given the differences in pathophysiology and mechanical circulatory support (MCS) between the RV and left ventricle (LV), the indications, goals, and contraindications of VA-ECMO as a rescue in cardiopulmonary arrest and pulmonary hypertensive crisis in patients with PH are discussed. Given the significant morbidity and mortality associated with PH, multidisciplinary teams including anesthesiologists, surgeons, cardiologists, pulmonologists, and psychological and social worker support should provide perioperative management.

Standardizing nomenclature in regional anesthesia: an ASRA-ESRA Delphi consensus study of abdominal wall, paraspinal, and chest wall blocks.

BACKGROUND: There is heterogeneity in the names and anatomical descriptions of regional anesthetic techniques. This may have adverse consequences on education, research, and implementation into clinical practice. We aimed to produce standardized nomenclature for abdominal wall, paraspinal, and chest wall regional anesthetic techniques. METHODS: We conducted an international consensus study involving experts using a three-round Delphi method to produce a list of names and corresponding descriptions of anatomical targets. After long-list formulation by a Steering Committee, the first and second rounds involved anonymous electronic voting and commenting, with the third round involving a virtual round table discussion aiming to achieve consensus on items that had yet to achieve it. Novel names were presented where required for anatomical clarity and harmonization. Strong consensus was defined as ≥75% agreement and weak consensus as 50% to 74% agreement. RESULTS: Sixty expert Collaborators participated in this study. After three rounds and clarification, harmonization, and introduction of novel nomenclature, strong consensus was achieved for the names of 16 block names and weak consensus for four names. For anatomical descriptions, strong consensus was achieved for 19 blocks and weak consensus was achieved for one approach. Several areas requiring further research were identified. CONCLUSIONS: Harmonization and standardization of nomenclature may improve education, research, and ultimately patient care. We present the first international consensus on nomenclature and anatomical descriptions of blocks of the abdominal wall, chest wall, and paraspinal blocks. We recommend using the consensus results in academic and clinical practice.

Analgesic efficacy of paraspinal interfascial plane blocks performed with the use of neurophysiology monitoring for posterior cervical laminectomy surgery: a case series.

Posterior cervical spine surgery often requires large posterior midline incision which can result in poorly controlled postoperative pain, arises from iatrogenic mechanical damage, intraoperative retraction and resection to structures such as bone, ligaments, muscles, intervertebral disks, and zygapophysial joints. Local anesthetics may be utilized for infiltration of the surgical wound; however, their analgesic efficacy has not been studied in this surgical approach. Here we report a case series. Given the potential for targeted sensory dorsal ramus nerve blocks to provide better and extended analgesia, we explored the feasibility of using cervical paraspinal interfascial plane (PIP) blocks in conjunction with neurophysiologic monitoring for postoperative analgesia after posterior cervical laminectomy. Our experience with the cervical paraspinal interfascial plane blocks has revealed that they can be used safely without affecting neurophysiologic monitoring and result in better pain control and reduced opiate use in the postoperative period. Cervical PIP blocks may be useful in controlling pain for posterior cervical laminectomy surgery without compromising neurophysiologic monitoring.

Postoperative opioid-free analgesia in elective bowel resection: Changes over time.

In the pain management evolution, opioid-free analgesia and multimodal analgesia strategies have emerged as feasible in many surgical settings including colorectal surgery. This was a retrospective cohort study including patients having undergone elective bowel resection between February 2012 and June 2018 aiming to evaluate whether there was reduction in opioid use after implementation of opioid-free analgesia in one medical centre. Trend analysis was conducted using Joinpoint regression employing nine-month intervals. The primary outcome for each interval was the proportion of patients receiving postoperative opioid-free analgesia, defined as forgoing all opioid analgesics after the day of surgery. This study showed a significant increasing trend in opioid-free analgesia in elective bowel resection from 0 to 42.5% over 4.5 years.

Thoracolumbar Dorsal Ramus Nerve Block Using Continuous Multiorifice Infusion Catheters: A Novel Technique for Postoperative Analgesia After Scoliosis Surgery.

BACKGROUND: This is a brief technical report about a novel regional anesthesia technique in which local anesthetic was deposited around the thoracolumbar dorsal rami nerves via 4 multiorifice pain catheters to obtain analgesia for posterior spinal fusion surgery on scoliosis patients. Scoliosis is the most common deformity of the spine. Currently, most surgeons prefer a dual rod, segmental spinal fixation system that allows multiple anchor points for attachment to the deformed spine. Scoliosis surgery is an extremely painful surgical procedure due to the large incision, surgical trauma to superficial and deep muscles of the back, and the insertion of pedicle screws and metal rods directly into the vertebral column. Postoperative pain management remains very challenging. METHODS: Three patients presented with scoliosis. Intraoperatively, 4 multiorifice catheters were placed lateral to the implanted pedicle screws. Two catheters were placed on each side, and a continuous infusion of 0.2 % ropivacaine was initiated postoperatively to improve the patient's pain control. The catheters remained in place for 48 hours postoperatively and were removed by the surgical team. Gentle traction was applied similar to the way epidural catheters are removed. RESULTS: All 3 patients reported very low pain scores, low doses of opioid consumption, and satisfaction with their pain control throughout their hospitalization. CONCLUSIONS: Our study results suggest that a thoracolumbar dorsal ramus nerve block using continuous multiorifice infusion catheters significantly improved postoperative comfort and pain and that its implementation into a multimodal analgesic regimen is relatively easy to achieve.

Erector spinae plane block unbound: Limits to safety in a patient with laminectomy.

The erector spinae plane (ESP) block has been used to provide analgesia for multiple surgeries involving the abdomen and thorax. Like other plane blocks, the ESP block relies upon normal anatomical boundaries for predictable and safe distribution of local anesthetic. Surgical intervention can alter the anatomy and present new considerations for performing plane blocks. We present a case in which an ESP block was performed for multiple rib fractures in a patient with a recent laminectomy. Laminectomy patients present unique considerations regarding the safety of the ESP block.

Exploring the transversus abdominis plane block in cesarean sections and the subsequent toxicity risk to neonates via breast milk.

The transversus abdominis plane (TAP) block with its wide application has shown to be an analgesic effective for use in abdominal surgeries, including for cesarean section. However, the bupivacaine delivered in the TAP block comes with the risk of toxicity, both central nerve system (CNS) and cardiovascular system, and has been shown in some instances to reach maximum serum concentrations in excess of the 2 µg/mL associated with the lower end of CNS toxicity. There is a specific concern with cesarean section TAP blocks of the anesthetic passage to the neonate via maternal breast milk and whether this poses a toxicity risk. Bupivacaine has been shown to pass into maternal milk at concentrations 0.34 times the maternal serum concentration. Preliminary statistical analyses suggest that the bupivacaine delivered in breast milk is not in concentrations high enough to cause neonatal toxicity, but further studies would be useful in identifying what the toxicity risk is, if any, to the neonates' breastfeeding after the delivery and TAP block.