Evaluación de la rehabilitación intensiva con bloqueo continuo del nervio supraescapular para el tratamiento de la capsulitis adhesiva refractaria de hombro. Serie de casos / Evaluation of intensive rehabilitation under continuous suprascapular nerve blockade for the treatment of refractory adhesive shoulder capsulitis. Case series

Introducción: El tratamiento de la capsulitis adhesiva refractaria de hombro es difícil. Este estudio observacional retrospectivo evaluó la efectividad a largo plazo del protocolo de fisioterapia intensiva con bloqueo periférico continuo del nervio supraescapular (BNSE). Método: Revisamos 29 historias clínicas de pacientes con capsulitis adhesiva y les tratamos con fisioterapia intensiva con BNSE durante 10 días. Se registraron los resultados del cuestionario de la escala DASH (Disabilities of the Arm, Shoulder and Hand Outcome Questionnaire) y los movimientos de hombro al inicio, a los 10 días de la infusión de anestésico local y transcurridos tres meses del procedimiento. Resultados: Veintiséis pacientes mejoraron los movimientos de hombro transcurridos 10 días de tratamiento. Se realizó seguimiento completo de 16 pacientes transcurridos tres meses del programa de rehabilitación. El rango de cuatro movimientos de hombro, compatible con una vida diaria normal, fue adquirido por nueve pacientes transcurridos tres meses. No se observó diferencia significativa en términos de movimiento de hombro entre la infusión de AL y transcurridos tres meses. Al finalizar la infusión, la puntuación DASH se redujo significativamente a 59,3 (n=26), y transcurridos tres meses se mantuvo en 42,1 (n=16). A los tres meses, el 33% de la población inicial alcanzó objetivamente los cuatro objetivos, compatibles con una calidad de vida correcta. Conclusión: La rehabilitación con BNSE está asociada a una mejora significativa a largo plazo en términos de movimiento de hombro y calidad de vida en los pacientes con capsulitis adhesiva. Son necesarios ensayos controlados aleatorizados para demostrar nuestros resultados alentadores.(AU)

Introduction: Treatment of refractory adhesive shoulder capsulitis is a challenge. This observational retrospective study evaluated the long-term effectiveness of intensive physiotherapy protocol under a continuous peripheral blockade of the suprascapular nerve (cSSNB). Method: We reviewed 29 medical records of patients suffering from adhesive capsulitis and treated with intensive physiotherapy under cSSNB during 10 days. The “disabilities of the arm, shoulder and hand” outcome questionnaire (DASH score) and shoulder movements were recorded at the beginning, 10 days after local anesthetic infusion and three months after. Results: Twenty six patients significant improved shoulder movements after 10 days of treatment. Sixteen patients were followed completely until 3 months after rehabilitation program. Range of four shoulder motion compatible with a normal daily life was acquired in nine patients at three months. There is no significant difference in shoulder motion between the end of LA infusion and at three months. At the end of infusion, DASH score is significantly decreased to 59.3 (n=26), and persists three months 42.1 (n=16). At three months, 33% of the initial population objectively reach the 4 goals, compatible with a correct quality of life. Conclusion: Rehabilitation under cSSNB is associated with a significant long term improvement in shoulder motion and quality of life in patients with adhesive capsulitis. Randomized controlled trials will be necessary to demonstrate our encouraging results.(AU)

Evaluation of intensive rehabilitation under continuous suprascapular nerve blockade for the treatment of refractory adhesive shoulder capsulitis. Case series.

INTRODUCTION: Treatment of refractory adhesive shoulder capsulitis is a challenge. This observational retrospective study evaluated the long-term effectiveness of intensive physiotherapy protocol under a continuous peripheral blockade of the suprascapular nerve (cSSNB). METHOD: We reviewed 29 medical records of patients suffering from adhesive capsulitis and treated with intensive physiotherapy under cSSNB during 10 days. The "disabilities of the arm, shoulder and hand" outcome questionnaire (DASH score) and shoulder movements were recorded at the beginning, 10 days after local anesthetic infusion and three months after. RESULTS: Twenty six patients significant improved shoulder movements after 10 days of treatment. Sixteen patients were followed completely until 3 months after rehabilitation program. Range of four shoulder motion compatible with a normal daily life was acquired in nine patients at three months. There is no significant difference in shoulder motion between the end of LA infusion and at three months. At the end of infusion, DASH score is significantly decreased to 59.3 (n = 26), and persists three months 42.1 (n = 16). At three months, 33% of the initial population objectively reach the 4 goals, compatible with a correct quality of life. CONCLUSION: Rehabilitation under cSSNB is associated with a significant long term improvement in shoulder motion and quality of life in patients with adhesive capsulitis. Randomized controlled trials will be necessary to demonstrate our encouraging results.

[Interscalene block and shoulder surgery. Literature review and new method of infiltration]. / Bloc interscalénique et chirurgie de l'épaule. Revue de la littérature et nouvelle méthode d'infiltration.

Nowadays, interscalene block is the gold standard for intra- and post-operative analgesia for shoulder surgery. It consists of distributing a sufficient volume of local anesthetics, within the interscalenic space which contains the C5 to C7 nerve roots. Due to its proximity to the area where the anesthetic is injected, the phrenic nerve can be transiently blocked causing a kind of paralysis of an hemidiaphragm. First, the use of ultrasound has reduced the incidence of diaphragmatic hemiparesis especially when the injection is performed at the C7 level rather than the C5 or C6 level. Then, decreasing the doses of local anesthetics has reduced the diffusion to the non-targeted structures, such as the phrenic nerve, causing less diaphragmatic hemiparesis. Finally, Palhais and Lee et al discovered that injecting LA at distance from the nerves roots can be useful in reducing this side effect. Based on their work, we decided to inject the local anesthetic into the muscle fascia. Our experience with this injection into the muscle itself seems to confirm the results described in the literature with less diaphragmatic hemiparesis. Further studies are needed to support our hypothesis and will be the subject of future researches in our institution.

De nos jours, le bloc interscalénique est la technique de référence pour l'analgésie per- et postopératoire de la chirurgie d'épaule. Il consiste à distribuer un volume d'anesthésique local suffisant, au sein du défilé inter-scalénique qui contient les racines nerveuses C5 à C7. En raison de sa proximité de la zone où est injecté l'anesthésique, le nerf phrénique peut être transitoirement bloqué engendrant une sorte de paralysie d'un hémidiaphragme. En premier, l'utilisation de l'échographie a permis de réduire l'incidence de l'hémiparésie diaphragmatique, surtout quand l'injection est réalisée au niveau C7 plutôt qu'au niveau C5 ou C6. Ensuite, la réduction des doses d'anesthésiques a diminué la diffusion vers des structures, autres que celles ciblées, telles que le nerf phrénique, engendrant moins d'hémiparésie diaphragmatique. Enfin, dans la même perspective, l'intérêt d'une injection à distance du plexus retrouvé par Palhais et Lee et coll. a diminué aussi cet effet secondaire. Sur base de leurs travaux, nous avons décidé d'injecter l'anesthésique local dans le fascia du muscle. Notre expérience avec cette injection au sein même du muscle semble confirmer les résultats décrits dans la littérature, avec moins d'hémiparésie diaphragmatique. D'autres études sont nécessaires pour étayer notre hypothèse et feront l'objet de futures recherches dans notre institution.

[Regional anesthesia: an extra-benefit for our patients]. / L'anesthésie locorégionale, un plus pour nos patients ....

Regional anesthesia is gaining popularity. It provides various benefits, including high quality postoperative analgesia. This leads to a diminished postoperative opioid consumption, less sensitization of peripheral and central neurons, and a reduced risk of persistent chronic pain. Moreover, regional blocks optimize functional recovery after surgery and improve the outcome of cancer patients who undergo surgery. They also reduce the risk of postoperative complications, especially wound complications. Also, regional blocks are frequently used in the management of chronic pain. Finally, in recent years, technological progress (such as the use of ultrasonography) has made these anesthesia techniques safer and more comfortable for the patient.

Clinical guidelines for the practice of peripheral nerve blocks in the adult.

These guidelines, made by BARA, are, like the "Safety First Guidelines" of the SARB, clinical recomendations for a good and safe practice when performing peripheral nerve blocks (PNB). These recommendations were made according to the most recent literature and experts opinion and are therefore prone to changes due to evolution of literature. The guidelines deal with "Informed Consent", preoperative visit, monitoring, equipment and the PNB procedure itself regardless of using ultrasound or neurostimultion or both. Advise is given when combining a PNB with general anesthesia and when a catheter technique is used.

Norepinephrine and ephedrine do not counteract the increase in cutaneous microcirculation induced by spinal anaesthesia.

BACKGROUND: Neuraxial anaesthesia improves tissue perfusion and tissue oxygen tension. Vasodilation induced by this technique may result in hypotension requiring the administration of vasoactive drugs. The use of peripheral vasoconstrictors might counteract the improved tissue perfusion and its potentially beneficial effects. We therefore investigated the effect of i.v. norepinephrine and ephedrine on skin perfusion using laser-Doppler flowmetry (LDF) in patients during spinal anaesthesia. METHODS: Skin blood flow expressed in perfusion units (PU) provided by LDF was measured simultaneously at the foot and the manubrium levels in 44 patients during spinal anaesthesia with a sensory level below T5. Norepinephrine infusion was then titrated to normalize mean arterial pressure (MAP) in 23 patients (Group NOR). Ephedrine (max. 10 mg) was administered in 21 patients (Group EPH). Changes in relative PU were compared between the two sites of measurements in each group during drug administration. The same doses of norepinephrine were assessed in 11 normal volunteers to assure comparable vasoreactivity at the foot and manubrium levels. RESULTS: Spinal anaesthesia resulted in a 10% decrease in MAP (P<0.001), an increase in relative PU values at the foot level (P<0.001), and a decrease at the sternum level (P<0.05). Norepinephrine and ephedrine produced a significant increase in relative PU values at the foot level when compared with the sternum level (NOR: P=0.02; EPH: P=0.0035). In volunteers, norepinephrine decreased cutaneous perfusion similarly at the manubrium and foot levels. CONCLUSIONS: Improved skin perfusion induced by spinal anaesthesia was not counteracted by the use of norepinephrine or ephedrine.

[Regional analgesia after lower limb orthopaedic surgery]. / Analgésie après chirurgie orthopédique du membre inférieur: intérêt de l'anesthésie locorégionale périphérique.

To provide postoperative analgesia, the anaesthesist has at his disposal a panel of different medications and also regional techniques of neural blockade. Loco-Regional analgesia (epidural or peripheral nerve block), by the use of local anaesthetics, blocks conduction of the painful influx to th central nervous system. Pain relief using peripheral nerve blocks after lower limb surgery represents as good alternative to the epidural analgesia and is superior to controlled analgesia with morphine. Peripheral nerve blocks, by decreasing the use of opioids in the postoperative period, reduce the incidence of side effects related to these molecules. They are also devoided of the adverse events due to the epidural analgesia like urinary retention or need for continuous monitoring. Analgesia after total knee prosthesis and hallux valgus surgery has considerably evolved. Postoperative analgesia is important in these cases: it facilitates physical therapy and improves patient's rehabilitation and satisfaction, it also shortens hospital stay. The aim of this review is to explain the different techniques of peripheral neural blockade and assess the value of this technique for the postoperative period after these two surgeries.

[Analgesia for wound dressing by continuous peripheral nerve block]. / Analgésie par blocs nerveux périphériques continus dans le cadre des soins de plaies cutanées.

We present the case of a patient with a circumferential venous ulcer at the level of the calf. She is hospitalized for surgical treatment by continuous aspiration dressing and coverage with skin graft. This patient presents a history of chronic pain, on which classical medications have few effects and are accompanied by side effects. After discussion with the patient, a double continuous peripheral nervous block (femoral and sciatic nerve) is set up to improve the tolerance to wound dressing. This technique presents favorable antalgic results. The indications and the different techniques of block performance (by electrostimulation or echo-guided) are described. The infectious risks related to the presence of catheter near cutaneous wounds are clarified according to recent data of literature. The relevance of these techniques in correlation with the development of chronic pain and on the trophicity of the wounds are also discussed.

Thromboprophylaxis in microsurgery.

Microsurgical free tissue transfer has become a gold standard in a wide range of clinical situations. Thrombosis at the anastomotic site is not only the most common cause of failure of microsurgical operations, but it is also one of the factors resulting in microcirculatory intravascular thrombosis in free flaps. All conditions of thrombus formation, defined by Virchow in 1856, are encountered in free flap surgery. This literature review concerns the problem of thromboprophylaxis in microsurgery. All citations published this last ten years (1996-2005) concerning this problem are noted. Data are confronted with other specialties, particularly vascular surgery, or with large retrospective studies. Protocol used in our institution is presented at the end of this lecture.

Effect of epidural bupivacaine on the relationship between the bispectral index and end-expiratory concentrations of desflurane.

We compared the relationship between the bispectral index and end-tidal desflurane concentrations in 20 patients undergoing elective surgery. Patients received epidurally either 10 ml saline (group S) or 10 ml bupivacaine 0.125% with epinephrine 1/800 000 (group B) before induction of anaesthesia with sufentanil (0.15 microgram.kg(-1)) and propofol (2 mg.kg(-1)); muscle relaxation was obtained with cisatracurium (0.2 mg.kg(-1)). Patients lungs were ventilated to maintain end-tidal desflurane at 3% in O2/N2O (50/50) until 5 min after skin incision, followed by two consecutive 10 min periods at end-tidal desflurane 6% and 9%. bispectral index values were recorded before induction, at 3% desflurane before and 5 min after skin incision, and at 6% and 9% end-tidal desflurane. Bispectral index decreased with increasing end-tidal desflurane concentration (ANOVA: p < 0.05). The decrease in bispectral index was significant between pre-induction, 3% and 6% desflurane. No significant difference was observed at 3% desflurane before and after skin incision, or between 6 and 9% desflurane. The relationship between bispectral index and end-tidal desflurane concentration was fitted by a linear regression in each group. No significant difference in bispectral index was observed between the groups at any time. We conclude that bispectral index decreases with increasing desflurane concentration and that this relationship is not affected by epidural 0.125% bupivacaine.