Novel ultrasound-guided supraclavicular stellate ganglion block.

INTRODUCTION: Stellate ganglion block (SGB) provides diagnostic and therapeutic benefits in pain syndromes in the head, neck, and upper extremity, including complex regional pain syndrome Types I and II, Raynaud's disease, hyperhidrosis, arterial embolism in the region of the arm. METHODS: We present a novel ultrasound-guided supraclavicular stellate ganglion block. Considering the existing anatomical structures of the targeted area. RESULTS AND CONCLUSIONS: We hope that we can provide fewer complications and additional benefits with this new approach.

Comparison of shoulder anterior capsular block and interscalene brachial plexus block for shoulder arthroscopy: a preliminary analysis.

BACKGROUND: This study aims to reveal the perioperative analgesic efficacy of a new technique, anterior capsular shoulder block, in treating pain after shoulder arthroscopy compared to the interscalene brachial plexus block. METHODS: The study design is randomized, prospective, interventional, standardized and double-blind in the setting of orthopedic operating room and orthopedic postoperative ward. Forty patients between 18-90 years of age and with American Society of Anesthesiologists Physical Status classification I to III who received arthroscopic cuff repair surgery were randomized into two (1:1 distribution; N.=20) groups. The interventions were interscalene brachial plexus block for Group A and shoulder anterior capsular block for Group B. Primary measurements were pain scores within 48 hours. Secondarily total analgesia requirement, intraoperative heart rate and blood pressure, arthroscopic image quality were evaluated. RESULTS: Pain scores within postoperative 48 hours were similar between SHAC and ISB groups with no significant difference (P>0.05). Total analgesia requirement, intraoperative and postoperative rescue analgesia, was also similar with no significance (P>0.05). CONCLUSIONS: This study demonstrated that the anterior capsular shoulder block is an effective alternative with similar results to the interscalene brachial plexus block for managing pain after shoulder arthroscopy.

Usefulness of ultrasound-guided serratus-anterior block in prevention of postoperative pain after breast surgery. A cohort study.

OBJECTIVE: To evaluate superficial serratus anterior plane block's efficacy and side effects in preventing postoperative pain after breast cancer surgery. METHODOLOGY: A prospective cohort study was conducted on 195 adult patients undergoing breast oncological surgery under general anesthesia (Group G, n = 96) or combined general anesthesia with superficial serratus anterior plane block (Group L, n = 99). Validated preoperative data, which are predictors of chronic postoperative pain of patients, were recorded (type of surgery, age, pain in the area of the intervention and the other regions; anesthetic-surgical data, analgesic doses used, duration of surgery; pain intensity (EVN scale) at immediate postoperative period, 24 h, seven days and one month after the surgery, and complications. RESULTS: Pain intensity, measured by the EVN scale, had a mean of 1.02 +/- 1.656 in the Postoperative Unit; 1.20 +/- 1.448 at 24 h; 0.76 +/- 1208 seven days; and 0.34 +/- 0.757 one month after surgery. Patients were operated under general anesthesia (n = 96) or general anesthesia combined with the interfascial block (n = 99). Significant differences (p < 0.05) were found in age, height, and VAS scale in PACU. Ten complications were recorded, six in Group L and four in Group G. There were no differences between groups in complications. CONCLUSIONS: Superficial serratus anterior plane blocks are effective and safe in pain control in the immediate postoperative period for breast cancer surgery as a part of the multimodal approach. No significant differences were found one week and one month after surgery.

Phenolysis for Advanced Shoulder Osteoarthritis: A Case Series of a Novel Ultrasound-Guided Approach to Anterior and Posterior Glenohumeral Articular Nerve Branches.

INTRODUCTION: The shoulder is one of the joints most affected by osteoarthritis, with a prevalence of almost 20% in adults over 65 years of age. Various treatments have been proposed to control osteoarthritis pain, including radiofrequency, pulsed and thermal, and recently cryoanalgesia. We propose in this series of cases a new approach to analgesic therapy with chemical denervation with phenol. MATERIALS AND METHOD: Patients who underwent phenolysis for shoulder osteoarthritis at our institutions in Italy and Australia between August 2022 and May 2023 were included. All patients included in our report provided written consent for publication. This chemical neurolysis technique consisted of two injections. First, the anterior shoulder capsule was denervated by a modified deep SHAC (Shoulder Anterior Capsule) approach to cover the anterior terminal articular branches of the axillary nerve, lateral pectoral nerve, and subscapularis nerve. Second, the posterior shoulder capsule was denervated by a posterior glenoid approach to cover the terminal articular branches of the suprascapular nerve (SSN).  Results: We included a total of 11 patients in this case series. Ten of 11 patients were affected by shoulder osteoarthritis, of which three had rotator cuff tendinopathy and three had full-thickness cuff tears. One patient had chronic subluxation of a shoulder prosthesis. After treatment, all patients significantly reduced pain immediately after treatment and, two weeks later, recovered joint movement and improved quality of life. No adverse events or loss of motor function following treatment. CONCLUSION: We presented a novel chemical approach to shoulder denervation, which was shown to be another effective way of improving pain and function in advanced glenohumeral arthritis.

Effect of Preoperative Anxiety on Depth of Anaesthesia and In Vitro Fertilization Success.

Objective: Infertility anxiety may have a harmful effect on embryo quality and fertilization during in vitro fertilization (IVF). Monitoring brain function gives real-time information about the depth of anaesthesia of a patient. This study examined the effect of preoperative anxiety on the depth of anaesthesia and IVF success. Methods: One hundred thirty-one patients who had undergone oocyte retrieval were divided into two groups according to the Beck Anxiety Inventory (BAI): the low-anxious Group L (n = 71) and high-anxious Group H (n = 60). Hemodynamic stability, intraoperative total propofol and fentanyl consumption, good quality embryo (GQE) rate, and fertilization rate were recorded. Results: Fertilization and GQE rates were not significant between groups L and H. Total propofol consumption was significantly higher in group H than in group L. Heart rate (HR) preoperatively and postoperatively and systolic arterial pressure (SAP) preoperatively and diastolic arterial pressure (DAP) postoperatively were significantly increased in group H than in group L. The time for the modified Aldrete score to reach 9 (MAS 9) in group H was significantly higher than that in group L. The effect of variables that were found significantly in the univariate analysis (Propofol, HRpreop, HRpostop, SAPpreop, DAPpostop, and MAS 9) on BAI score. Conclusion: Total propofol consumption was higher in patients with high anxiety levels, but it did not have a negative effect on IVF success.

Nitrous oxide for the treatment of complex regional pain syndrome: a randomized blinded trial.

INTRODUCTION: Complex Regional Pain Syndrome (CRPS) is a debilitating neuropathic condition often refractory to conventional treatments. N-methyl-D-aspartate (NMDA) receptor antagonists have a well-established role in the development and modulation of chronic neuropathic pain. Nitrous oxide is widely used and generally safe anesthetic gas with NMDA receptor antagonist activity. We therefore tested the hypothesis that brief periods of nitrous oxide exposure reduce pain in patients with CRPS. METHODS: Patients with a diagnosis of CRPS were randomized to either 2 hours of nitrous oxide exposure on three alternating days (Nitrous Oxide) versus a placebo air/oxygen mixture (Air-Oxygen). Our primary outcome was patient-reported pain scores at 1 week and 1 month. Secondary and exploratory outcomes were physical and mental health (PRMOIS-29 v2 survey), specific neuropathic pain symptoms (McGill short-form questionnaire), and opioid consumption. RESULTS: 44 patients participated in the study; 20 were randomized to Nitrous Oxide and 24 were assigned to Air-Oxygen. Pain scores did not differ significantly, with the estimated difference in means (Nitrous Oxide-Air-Oxygen) of -0.57 (95% CI: -1.42 to 0.28) points, p=0.19. There were also no differences detected in secondary outcomes, with the estimated difference in mean Z-scores for physical health (Nitrous Oxide-Air-Oxygen) of 0.13 (95% CI: -0.16 to 0.43), mental health 0.087 (95% CI: -0.31 to 0.48), and Patient Global Impression of Change score -0.7 (95% CI: -1.85 to 0.46). CONCLUSIONS: Compared with air/oxygen, 2 hours of nitrous oxide/oxygen exposure for three sessions did not provide meaningful therapeutic potential for patients with chronic CRPS. Our results do not support using nitrous oxide for the treatment of CRPS.

Cost Analysis of Low-Volume Versus Standard-Volume Ultrasound-Guided Interscalene Brachial Plexus Block in Arthroscopic Shoulder Surgery.

Background Economic evaluation has become an essential decision-making tool for health systems worldwide. This study was aimed at estimating the difference in the use of healthcare resources, days on sick leave, and costs between patients undergoing a standard-volume versus a low-volume ultrasound-guided interscalene brachial plexus block. Methods This is a post-hoc cost analysis of a double-blind, randomized, and controlled clinical trial. Forty-eight patients undergoing ultrasound-guided interscalene block received either 10 ml or 20 ml of levobupivacaine 0.25%. Analyses involved the public healthcare payer perspective (including visits to general practitioners, nursing staff, physiotherapy facilities, hospital admissions, outpatient diagnostic tests, etc.) and the limited societal perspective, including productivity losses (days on sick leave). Measurements were made at one-month and one-year follow-ups post-intervention. Differences in costs were estimated using two-part models adjusted by the costs incurred in the previous year. Results Subjects in the 10 ml group made greater use of general practitioner visits (mean difference [95% CI]: 3.35 [0.219 to 6.49]; p=0.036) and diagnostic tests (2.43 [0.601 to 4.26]; p=0.009), but less use of physical therapy (-12.9 [-21.7 to -4.06]; p=0.004). Mean (SD) cost differences from the public healthcare payer's perspective were 1,461.34 $ (1,541.62) and 1,024.08$ (943.83) for the 10 ml and 20 ml groups, respectively (p=0.293). From the limited societal perspective, the differences were as follows: 7,036.53$ (8,077.58) and 8,666.56$ (9,841.10), respectively (p=0.937). While there were no differences in the above parameters at the one-month follow-up. Conclusion The volume reduction proposed following interscalene block resulted in meaningful, albeit not statistically significant, clinical benefits and lower costs from a limited societal perspective for shoulder surgery. Thus, healthcare use and days on sick leave are variables to be taken into consideration when calculating the economic impact of surgical procedures.

The Booster Effect of a Single Quarterly Dose of Hyaluronic Acid in Knee Osteoarthritis: Five-Year Results of a Registry-Based Study.

Objective Viscosupplementation by hyaluronic acid (HA) is well established non-surgical treatment of knee osteoarthritis (KOA). This registry-based study investigated the booster effect of a quarterly intra-articular single knee injection (30mg/2ml) for five years. Methods Sixty patients, including 29 males and 31 females, with a mean ± SD age 61.07 ± 9.15 with Kellgren-Lawrence grade I-III KOA, have been selected from a registry of interventional treatments for musculoskeletal pain conditions. To be eligible, patients had to be treated with a single quarterly intraarticular injection of HA with a follow-up of at least five years and assessed with Western Ontario and McMaster Universities Arthritis Index (WOMAC) and Numeric Rating Scale (NRS) at baseline and after each HA injection in the first 24 months and at 36, 48, and 60 months. Results Sixty of 63 patients enrolled in this study completed the 60 months of follow-up. Patients had a marked improvement in knee function and pain, expressed by the significant reduction in WOMAC (T0 48.62±8.95 vs. T11 10.75±4.36; p<0.0001) and NRS scores (6.38±1.06 vs. T11 0.95±0.89 p<0.0001) from the baseline to the end of the follow-up period. Conclusion A quarterly injection of HA provides a rapid, safe, and stable long-term reduction of pain and improvement of function in elderly people with mild to moderate knee osteoarthritis along a five-year period of treatment and follow-up. Further investigations are necessary to confirm these findings.

Postoperative Analgesia and Palliative Care of Peng Block for Terminal Osteosarcoma.

Palliative care involves patients with a high incidence of chronic pain and inadequate treatment related to opioid abuse. In terminal patients, the side effects of opioids may result in lower quality of life due to their deleterious immunosuppression and gastrointestinal effects. In our routine clinical practice, we consider the ultrasound-guided PENG block as a palliative analgesic technique to improve end-of-life care to terminal patients.

Efficacy of Acupuncture, Intravenous Lidocaine, and Diet in the Management of Patients with Fibromyalgia: A Systematic Review and Network Meta-Analysis.

Introduction: This network meta-analysis aimed to assess the efficacy of acupuncture, intravenous lidocaine, and diet compared with other comparators such as physiotherapy and sham/placebo in fibromyalgia patients. Materials and Methods: We searched Embase, PubMed, Scopus, and Web of Science for relevant studies till September 2021. The included studies were randomized controlled clinical trials. For the network meta-analysis, we used the R software. Results: There were 23 included RCTs. The total sample size was 1409 patients. Compared with the sham/placebo group, the network analysis showed the highest improvement in the quality of life in the acupuncture group standardized mean difference (SMD) = -10.28, 95%-CI [-14.96; -5.59]), and then in the physiotherapy group (SMD = -7.48, 95%-CI [-14.72; -0.23]). For the pain, there was a significant reduction with acupuncture (SMD = -1.69, 95%-CI [-2.48; -0.89]), compared with sham/placebo. Regarding depression, it showed a significant reduction with acupuncture (SMD = -9.64, 95%-CI [-16.13; -3.14]) compared with sham/placebo. Finally, for stiffness, it showed no significant differences in the stiffness between acupuncture (SMD = -8.52, 95%-CI [-20.40; 3.36]), fluoxetine (SMD = -6.52, 95%-CI [-29.65; 16.61]), and physiotherapy (SMD = -4.64, 95%-CI [-22.83; 13.54]) compared with sham/placebo. Conclusions: The acupuncture showed a significant effect in the management of fibromyalgia patients. It reduced pain, depression, and enhanced the quality of life. While physiotherapy showed a significant improvement in the quality of life only. In contrast, intravenous lidocaine and diet showed no significant differences when compared with sham/placebo.

Beyond the Pericapsular Nerve Group (PENG) Block: A Narrative Review.

The pericapsular nerve group block shows promising results in providing pain relief with a potential motor-sparing effect in hip fracture patients. In this narrative review, we analyze the published articles, and we describe the structures achieved when performing the block. We conducted a literature search to identify the articles performing the pericapsular nerve group block, in the adult or paediatric population, from November 1, 2018, to May 15, 2021. Of the 68 selected articles, 38 were considered eligible, including 1 double-blinded randomized comparative trial, 4 observational studies, and 33 case series and case reports. The technique was described in both acute and chronic pain settings, mainly performed as single shot. All studies described effective analgesia. Quadriceps weakness was experienced in some patients. It has been described as easy to perform and has a low rate of complications. It lacks, however, adequately powered randomized controlled trials to assess its clinical value and efficacy.

Permeable spaces between glenohumeral ligaments as potential gateways for rapid regional anesthesia of the shoulder.

Shoulder pain is a highly prevalent condition, often resulting in major life limitations, and requiring effective treatments. In this work, we explore the anatomical basis of a proposed approach to the regional anesthesia of the shoulder through a single injection under the subscapularis muscle. Bilateral experimental injections in shoulders from body donors (Radiolar ® and Methylene-Blue) under the subscapular muscle (n = 11) and cadaveric systematic dissections of other 35 shoulders from body donors were performed. Injectate spread was then qualitatively assessed. Long axis of permeable foramina in the anterior aspect of the shoulder joint capsule was measured in centimeters using a digital caliper. More than 40% of specimens had at least one permeable space (Weitbrech and/or Rouvière foramina) communicating the subscapular bursa and the articular space. We further demonstrate that an ultrasonography-guided injection under the subscapularis muscle allows the spread of the injectate through the anterior, inferior and posterodorsal walls of the articular capsule, the subacromial bursa, and the bicipital groove, as well as into the articular space for some injections. The odds of accidental intraarticular injection decrease when injecting with low volumes. This anatomical study provides a detailed description of foramina between glenohumeral ligaments. Furthermore, the data shown in this work supports, as a proof of concept, a safe alternative for rapid and specific blockade of terminal sensory branches innervating the shoulder joint capsule.

Evaluation of Interfascial Plane and Pericapsular Nerve Blocks to the Shoulder Joint: A Preliminary Analysis of Shoulder Anterior Capsular Block.

INTRODUCTION: The aim of this study is to verify if the shoulder anterior capsular block (SHAC), combined with other nerve blocks, is effective in relieving shoulder pain, avoiding motor block and allowing an early rehabilitation program. METHODS: Seventy-five consecutive patients with painful shoulder were treated with the SHAC, alone (30 patients) or in combination with a suprascapular nerve block (SSnb: 25 patients) or with pectoralis and serratus plane block (PECS-2: 20 patients). All blocks were performed with 0.2% ropivacaine plus 8 mg dexamethasone. All patients were treated with three-weekly physiotherapy sessions for the following 2 weeks and then with home exercises. RESULTS: The post-procedural analgesic effect was strong in all groups, with a mean change in numeric rating scale (NRS) values of -6.05 in group 1, -6.25 in group 2, and -6.19 in group 3 (p < .0001), allowing all patients to complete an immediate physiotherapy session. Only a few patients needed to repeat the procedure 1 week after the first treatment for the recurrence of pain. From the treatment to the end of the follow-up, we noted a further drop in mean pain NRS values of 1.90 in group 1 and 1.80 in groups 2 and 3. No difference in effect over time was observed among the different groups. No adverse event or motor block was recorded. CONCLUSION: This study demonstrates that the SHAC, alone or in combination with other peripheral nerve blocks, is an attractive alternative for shoulder pain management, especially when physiotherapy is required to recover shoulder function.

Is the heart rate variability monitoring using the analgesia nociception index a predictor of illness severity and mortality in critically ill patients with COVID-19? A pilot study.

INTRODUCTION: The analysis of heart rate variability (HRV) has proven to be an important tool for the management of autonomous nerve system in both surgical and critically ill patients. We conducted this study to show the different spectral frequency and time domain parameters of HRV as a prospective predictor for critically ill patients, and in particular for COVID-19 patients who are on mechanical ventilation. The hypothesis is that most severely ill COVID-19 patients have a depletion of the sympathetic nervous system and a predominance of parasympathetic activity reflecting the remaining compensatory anti-inflammatory response. MATERIALS AND METHODS: A single-center, prospective, observational pilot study which included COVID-19 patients admitted to the Surgical Intensive Care Unit was conducted. The normalized high-frequency component (HFnu), i.e. ANIm, and the standard deviation of RR intervals (SDNN), i.e. Energy, were recorded using the analgesia nociception index monitor (ANI). To estimate the severity and mortality we used the SOFA score and the date of discharge or date of death. RESULTS: A total of fourteen patients were finally included in the study. ANIm were higher in the non-survivor group (p = 0.003) and were correlated with higher IL-6 levels (p = 0.020). Energy was inversely correlated with SOFA (p = 0.039) and fewer survival days (p = 0.046). A limit value at 80 of ANIm, predicted mortalities with a sensitivity of 100% and specificity of 85.7%. In the case of Energy, a limit value of 0.41 ms predicted mortality with all predictive values of 71.4%. CONCLUSION: A low autonomic nervous system activity, i.e. low SDNN or Energy, and a predominance of the parasympathetic system, i.e. low HFnu or ANIm, due to the sympathetic depletion in COVID-19 patients are associated with a worse prognosis, higher mortality, and higher IL-6 levels.