Arthroscopic medial meniscus trimming or repair under nerve blocks: Which nerves should be blocked?

BACKGROUND: This study aimed to determine the role of the sciatic and obturator nerve blocks (in addition to femoral block) in providing painless arthroscopic medial meniscus trimming/repair. MATERIALS AND METHODS: One hundred and twenty patients with medial meniscus tear, who had been scheduled to knee arthroscopy, were planned to be included in this controlled prospective double-blind study. The patients were randomly allocated into three equal groups; FSO, FS, and FO. The femoral, sciatic, and obturator nerves were blocked in FSO groups. The femoral and sciatic nerves were blocked in FS group, while the femoral and obturator nerves were blocked in FO group. Intraoperative pain and its causative surgical maneuver were recorded. RESULTS: All the patients (n = 7, 100%) in FO group had intraoperative pain. The research was terminated in this group but completed in FS and FSO groups (40 patients each). During valgus positioning of the knee for surgical management of the medial meniscus tear, the patients in FS group experienced pain more frequently than those in FSO group (P = 0.005). CONCLUSION: Adding a sciatic nerve block to the femoral nerve block is important for painless knee arthroscopy. Further adding of an obturator nerve block may be needed when a valgus knee position is required to manage the medial meniscus tear.

Therapeutic potential of human olfactory bulb neural stem cells for spinal cord injury in rats.

STUDY DESIGN: Adult human olfactory bulb neural stem cells (OBNSCs) were isolated from human patients undergoing craniotomy for tumor resection. They were genetically engineered to overexpresses green fluorescent protein (GFP) to help trace them following engraftment. Spinal cord injury (SCI) was induced in rats using standard laminectomy protocol, and GFP-OBNSC were engrafted into rat model of SCI at day 7 post injury. Three rat groups were used: (i) Control group, (ii) Sham group (injected with cerebrospinal fluid) and treated group (engrafted with OBNSCs). Tissues from different groups were collected weekly up to 2 months. The collected tissues were fixed in 4% paraformaldehyde, processed for paraffin sectioning, immunohistochemically stained for different neuronal and glial markers and examined with bright-field fluorescent microscopy. Restoration of sensory motor functions we assessed on a weekly bases using the BBB score. OBJECTIVES: To assess the therapeutic potential of OBNSCs-GFP and their ability to survive, proliferate, differentiate and to restore lost sensory motor functions following their engraftment in spinal cord injury (SCI). METHODS: GFP-OBNSC were engrafted into a rat model of SCI at day 7 post injury and were followed-up to 8 weeks using behavioral and histochemical methods. RESULTS: All transplanted animals exhibited successful engraftment. The survival rate was about 30% of initially transplanted cells. Twenty-seven percent of the engrafted cells differentiated along the NG2 and O4-positive oligodendrocyte lineage, 16% into MAP2 and ß-tubulin-positive neurons, and 56% into GFAP-positive astrocytes. CONCLUSION: GFP-OBNSCs had survived for >8 weeks after engraftment and were differentiated into neurons, astrocytes and oligodendrocytes, The engrafted cells were distributed throughout gray and white matter of the cord with no evidence of abnormal morphology or any mass formation indicative of tumorigenesis. However, the engrafted cells failed to restore lost sensory and motor functions as evident from behavioral analysis using the BBB score test.

Ropivacaine in ultrasound-guided femoral nerve block: what is the minimal effective anaesthetic concentration (EC90)?

The objective of this study was to estimate the minimal effective anaesthetic concentrations of ropivacaine required to block the femoral nerve in 90% of patients. Forty-five patients who had knee surgery received ultrasound-guided femoral nerve block using 15 ml ropivacaine. The ropivacaine concentration given to a patient relied on the efficacy of the block in the previous patient, using the biased-coin design up-down sequential method. In the event of successful block, the next patient was randomly assigned to receive either the same ropivacaine concentration or a concentration 0.02% w/v less. In the event of a failed block, the next patient received a concentration 0.02% w/v higher. Successful block was defined as complete sensory and motor block before surgery together with pain-free surgery. The minimal effective ropivacaine concentration was estimated to be 0.167% w/v (95% CI 0.14-0.184%). Perineural injection of 15 ml ropivacaine 0.167% w/v under ultrasound guidance can provide successful femoral nerve block in 90% of patients.

Lidocaine use in ultrasound-guided femoral nerve block: what is the minimum effective anaesthetic concentration (MEAC90)?

BACKGROUND: This study aimed to estimate the minimum effective anaesthetic concentrations of lidocaine required to block the femoral nerve under ultrasound (US) guidance in 90% (MEAC90) of patients. METHODS: A minimum of 45 patients who had undergone knee arthroscopy were included in this observational study. All the patients received US-guided sciatic, obturator, and femoral nerve blocks. The femoral nerve block was performed using 15 ml of lidocaine. The lidocaine concentration given to a patient was determined by the response of the previous patient (a biased-coin design up-down sequential method). If a patient had a negative response, the lidocaine concentration was increased by 0.1% w/v in the next patient. If a patient had a positive response, the next patient was randomized to receive the same lidocaine concentration (with a probability of 0.89) or to receive a concentration 0.1% w/v less (with a probability of 0.11). A positive response was defined as complete sensory and motor block. The patients' responses were analysed to calculate the mean MEAC90. RESULTS: Fifty-two patients were required to complete the study; 45 had a positive response and seven had a negative response. The mean MEAC90 was estimated to be 0.93% w/v [95% confidence interval (CI), 0.8-1.03%]. Lidocaine 0.93% w/v was estimated to produce a successful block in 89% (95% CI, 78-100%) of patients. CONCLUSIONS: Perineural injection of 15 ml of lidocaine 0.93% w/v under US guidance could provide successful femoral nerve block in 90% of patients.

Lidocaine vs. magnesium: effect on analgesia after a laparoscopic cholecystectomy.

BACKGROUND: This double-blinded study aimed at evaluating and comparing the effects of magnesium and lidocaine on pain, analgesic requirements, bowel function, and quality of sleep in patients undergoing a laparoscopic cholecystectomy (LC). METHODS: Patients were randomized into three groups (n=40 each). Group M received magnesium sulfate 50 mg/kg intravenously (i.v.), followed by 25 mg/kg/h i.v., group L received lidocaine 2 mg/kg i.v., followed by 2 mg/kg/h i.v., and group P received saline i.v. Bolus doses were given over 15 min before induction of anesthesia, followed by an i.v. infusion through the end of surgery. Intraoperative fentanyl consumption and averaged end-tidal sevoflurane concentration were recorded. Abdominal and shoulder pain were evaluated up to 24 h using a visual analog scale (VAS). Morphine consumption was recorded at 2 and 24 h, together with quality of sleep and time of first flatus. RESULTS: Lidocaine or magnesium reduced anesthetic requirements (P<0.01), pain scores (P<0.05), and morphine consumption (P<0.001) relative to the control group. Lidocaine resulted in lower morphine consumption at 2 h [4.9 + or - 2.3 vs. 6.8 + or - 2.8 (P<0.05)] and lower abdominal VAS scores compared with magnesium (1.8 + or - 0.8 vs. 3.2 + or - 0.9, 2.2 + or - 1 vs. 3.6 + or - 1.6, and 2.1 + or - 1.4 vs. 3.3 + or - 1.9) at 2, 6, and 12 h, respectively (P<0.05). Lidocaine was associated with earlier return of bowel function and magnesium was associated with better sleep quality (P<0.05). CONCLUSION: I.v. lidocaine and magnesium improved post-operative analgesia and reduced intraoperative and post-operative opioid requirements in patients undergoing LC. The improvement of quality of recovery might facilitate rapid hospital discharge.

Addition of clonidine or dexmedetomidine to bupivacaine prolongs caudal analgesia in children.

BACKGROUND: Caudal block is a common technique for paediatric analgesia but with the disadvantage of short duration of action after single injection. Caudal dexmedetomidine and clonidine could offer significant analgesic benefits. We compared the analgesic effects and side-effects of dexmedetomidine and clonidine added to bupivacaine in paediatric patients undergoing lower abdominal surgeries. METHODS: Sixty patients (6 months to 6 yr) were evenly and randomly assigned into three groups in a double-blinded manner. After sevoflurane in oxygen anaesthesia, each patient received a single caudal dose of bupivacaine 0.25% (1 ml kg(-1)) combined with either dexmedetomidine 2 microg kg(-1) in normal saline 1 ml, clonidine 2 microg kg(-1) in normal saline 1 ml, or corresponding volume of normal saline according to group assignment. Haemodynamic variables, end-tidal sevoflurane, and emergence time were monitored. Postoperative analgesia, use of analgesics, and side-effects were assessed during the first 24 h. RESULTS: Addition of dexmedetomidine or clonidine to caudal bupivacaine significantly promoted analgesia time [median (95% confidence interval, CI): 16 (14-18) and 12 (3-21) h, respectively] than the use of bupivacaine alone [median (95% CI): 5 (4-6) h] with P<0.001. However, there was no statistically significant difference between dexmedetomidine and clonidine as regards the analgesia time (P=0.796). No significant difference was observed in incidence of haemodynamic changes or side-effects. CONCLUSIONS: Addition of dexmedetomidine or clonidine to caudal bupivacaine significantly promoted analgesia in children undergoing lower abdominal surgeries with no significant advantage of dexmedetomidine over clonidine and without an increase in incidence of side-effects.

Expression and localization of growth factors and their receptors in the mammalian testis. Part I: Fibroblast growth factors and insulin-like growth factors.

It is now well established that normal development and function of testis are mediated by endocrine and paracrine pathways including hormones, growth factors and cytokines as well as by direct cell-to-cell contacts depending on tight, adhering and gap junctions. In the last two decades, several growth factors were identified in the testis of various mammalian species. Growth factors are shown to promote cell proliferation, regulate tissue differentiation, and modulate organogenesis. Interestingly, most of these peptides are expressed not only in the adult mammalian testis during spermatogenesis but also during testicular morphogenesis in prenatal and postnatal life. Our study was launched to provide an overview of the expression, localization, and putative physiological roles of growth factors and their receptors in the mammalian testis. The growth factors considered in this part of our review are fibroblast growth factors and insulin-like growth factors. These factors are found in testicular cells in prenatal, postnatal, and adult animals and are implicated in the regulation of important testicular activities including testicular cord morphogenesis, modulation of testicular hormone secretion and control of spermatogenesis.