9. Chronic knee pain.

INTRODUCTION: Chronic knee pain is defined as pain that persists or recurs over 3 months. The most common is degenerative osteoarthritis (OA). This review represents a comprehensive description of the pathology, diagnosis, and treatment of OA of the knee. METHODS: The literature on the diagnosis and treatment of chronic knee pain was retrieved and summarized. A modified Delphi approach was used to formulate recommendations on interventional treatments. RESULTS: Patients with knee OA commonly present with insidious, chronic knee pain that gradually worsens. Pain caused by knee OA is predominantly nociceptive pain, with occasional nociplastic and infrequent neuropathic characteristics occurring in a diseased knee. A standard musculoskeletal and neurological examination is required for the diagnosis of knee OA. Although typical clinical OA findings are sufficient for diagnosis, medical imaging may be performed to improve specificity. The differential diagnosis should exclude other causes of knee pain including bone and joint disorders such as rheumatoid arthritis, spondylo- and other arthropathies, and infections. When conservative treatment fails, intra-articular injections of corticosteroids and radiofrequency (conventional and cooled) of the genicular nerves have been shown to be effective. Hyaluronic acid infiltrations are conditionally recommended. Platelet-rich plasma infiltrations, chemical ablation of genicular nerves, and neurostimulation have, at the moment, not enough evidence and can be considered in a study setting. The decision to perform joint-preserving and joint-replacement options should be made multidisciplinary. CONCLUSIONS: When conservative measures fail to provide satisfactory pain relief, a multidisciplinary approach is recommended including psychological therapy, integrative treatments, and procedural options such as intra-articular injections, radiofrequency ablation, and surgery.

Positive airway pressure therapy for chronic pain in patients with obstructive sleep apnea-a systematic review.

PURPOSE: Obstructive sleep apnea (OSA) is prevalent in patients with chronic non-cancer pain. OSA may lead to low sleep quality and an increase in pain sensitivity. Patients reporting greater sleep impairment tend to experience higher pain intensity and vice versa. Positive airway pressure (PAP) is the current gold standard treatment for OSA. This review aims to evaluate the efficacy of PAP therapy in patients with comorbid chronic pain and OSA in influencing pain outcomes like pain intensity, tolerance, threshold, and sensitivity. METHODS: We performed a systematic literature search for studies published after 1990, utilizing the following databases: Medline, Medline In-Process/ePubs, Embase, Cochrane CENTRAL, and the Cochrane Database of Systematic Reviews. Search terms included "chronic pain," "sleep disorders," and "positive airway pressure." RESULTS: Of 1982 initial studies, ten studies met the study inclusion criteria. Seven of these studies examined the effect of PAP therapy on chronic pain, of which five demonstrated improved pain outcomes, specifically, headache pain. The effect of PAP therapy on chronic non-headache pain was found to be inconclusive. When examining the three studies that did not involve chronic pain patients, PAP therapy effectively increased pain threshold and tolerance in two studies (p = 0.03 and p = 0.01). CONCLUSION: An association exists between PAP therapy and decreased chronic headache outcomes in patients with OSA. Additionally, research shows that PAP therapy may increase pain tolerance and threshold. Future high-quality evidence is required to further investigate the association between PAP and non-headache chronic pain.

Frequency and characteristics of patient exclusion criteria in Canadian multidisciplinary pain treatment facilities: a cross-sectional study.

PURPOSE: A multidisciplinary approach is recommended for patients with complex chronic pain (CP). Many multidisciplinary pain treatment facilities (MTPFs) use patient exclusion criteria but little is known about their characteristics. The objective of this study was to describe the frequency and characteristics of exclusion criteria in public Canadian MTPFs. METHODS: We conducted a cross-sectional study in which we defined an MPTF as a clinic staffed with professionals from three disciplines or more (including at least one medical specialty) and whose services were integrated within the facility. We disseminated a web-based questionnaire in 2017-2018 to the administrative leads of MPTFs across the country. They were invited to complete the questionnaire about the characteristics of their facilities. Data were analyzed using descriptive statistics and correlation measures. RESULTS: A total of 87 MTPFs were included in the analyses. Half of them (52%) reported using three exclusion criteria or more. There was no significant association between the number of exclusion criteria and wait time for a first appointment or number of new consultations in the past year. Fibromyalgia and migraine were the most frequently excluded pain syndromes (10% and 7% of MPTFs, respectively). More than one MPTF out of four excluded patients with mental health disorders (30%) and/or substance use disorders (29%), including MPTFs with specialists in their staff. CONCLUSIONS: Multidisciplinary pain treatment facility exclusion criteria are most likely to affect CP patients living with complex pain issues and psychosocial vulnerabilities. Policy efforts are needed to support Canadian MPTFs in contributing to equitable access to pain management.

RéSUMé: OBJECTIF: Une approche multidisciplinaire est recommandée pour les patients souffrant de douleur chronique (DC) complexe. De nombreux centres multidisciplinaires de traitement de la douleur (CMTD) utilisent des critères d'exclusion des patients, mais on ne sait que peu de choses sur leurs caractéristiques. L'objectif de cette étude était de décrire la fréquence et les caractéristiques des critères d'exclusion dans les CMTD publics canadiens. MéTHODE: Nous avons mené une étude transversale dans laquelle nous avons défini un CMTD comme une clinique composée de professionnels de trois disciplines ou plus (y compris au moins une spécialité médicale) et dont les services étaient intégrés à l'établissement. En 2017-2018, nous avons fait parvenir un questionnaire en ligne aux responsables administratifs des CMTD partout au pays. Ils ont été invités à remplir le questionnaire sur les caractéristiques de leurs établissements. Les données ont été analysées à l'aide de statistiques descriptives et de mesures de corrélation. RéSULTATS: Au total, 87 CMTD ont été inclus dans les analyses. La moitié d'entre eux (52 %) ont déclaré utiliser trois critères d'exclusion ou plus. Il n'y avait pas d'association significative entre le nombre de critères d'exclusion et le temps d'attente pour un premier rendez-vous ou le nombre de nouvelles consultations au cours de la dernière année. La fibromyalgie et la migraine étaient les syndromes douloureux les plus fréquemment exclus (10 % et 7 % des CMTD, respectivement). Plus d'un CMTD sur quatre excluait les patients atteints de troubles de santé mentale (30 %) et/ou de troubles liés à l'utilisation de substances (29 %), y compris les CMTD comptant des spécialistes dans leur personnel. CONCLUSION: Les critères d'exclusion des centres multidisciplinaires de traitement de la douleur sont plus susceptibles d'affecter les patients atteints de douleur chronique vivant avec des problèmes de douleur complexes et des vulnérabilités psychosociales. Des efforts au niveau des politiques sont nécessaires pour aider les CMTD canadiens à favoriser un accès équitable à la prise en charge de la douleur.

Anatomical Study of the Innervation of Triangular Fibrocartilage Complex and Distal Radioulnar and Radiocarpal Joints: Implications for Denervation.

PURPOSE: Open and percutaneous denervation is an emerging technique for joint pain. This study investigated the course and distribution of the articular branches innervating the triangular fibrocartilage complex (TFCC), distal radioulnar joint (DRUJ), and radiocarpal joint (RCJ) relative to bony and soft tissue landmarks to guide wrist denervation procedures. METHODS: Fourteen formalin-embalmed specimens were serially dissected to expose the origin, course, and distribution of articular branches innervating the TFCC, DRUJ, and RCJ. Bony and soft tissue landmarks to localize each articular branch were documented and visualized on a 3-dimensional reconstruction of the bones of the distal forearm and hand. RESULTS: The TFCC was innervated by articular branches from the posterior interosseus nerve (10 of 14 specimens), dorsal cutaneous branch of the ulnar nerve (14 of 14 specimens), palmar cutaneous branch of the ulnar nerve (12 of 14 specimens), and medial antebrachial cutaneous nerve (9 of 14 specimens). The DRUJ was innervated by the posterior interosseus nerve (9 of 14 specimens) and anterior interosseus nerve (14 of 14 specimens). The RCJ was innervated by the posterior interosseus nerve (14 of 14 specimens), superficial branch of the radial nerve (5 of 14 specimens), lateral antebrachial cutaneous nerve (14 of 14 specimens), and palmar cutaneous branch of the median nerve (10 of 14 specimens). CONCLUSIONS: Multiple nerves were found to innervate the TFCC, DRUJ, and RCJ. The relationship of anatomical landmarks to specific articular branches supplying the TFCC, DRUJ, and RCJ can inform selective denervation procedures based on the structural origin of pain. CLINICAL RELEVANCE: The detailed documentation of the spatial relationship of the nerve supply to the wrist provides clinicians with the anatomical basis to optimize current, and develop new denervation protocols to manage chronic wrist pain.

Chemical Ablation of Genicular Nerve with Phenol for Pain Relief in Patients with Knee Osteoarthritis: A Prospective Study.

BACKGROUND: Radiofrequency ablation of the genicular nerve is performed for knee osteoarthritis (KOA) when conservative treatment is not effective. Chemical ablation may be an alternative, but its effectiveness and safety have not been examined. The objective of this prospective open-label cohort study is to evaluate the effectiveness and safety of ultrasound-guided chemical neurolysis for genicular nerves with phenol to treat patients with chronic pain from KOA. METHODS: Forty-three patients with KOA with pain intensity score (Numeric Rating Scale, NRS) ≥ 4, and duration of pain of more than 6 months were considered for enrollment. Ultrasound-guided diagnostic blocks of genicular nerves (superomedial, inferomedial, and superolateral) with 1.5 mL of 0.25% bupivacaine at each site were performed. Those who reported more than 50% reduction in NRS went on to undergo chemical neurolysis, using 1.5 mL 7% glycerated phenol in each genicular nerve. NRS and Western Ontario and McMaster Universities Arthritis Index (WOMAC) scores were assessed before intervention and at 2 weeks and 1, 2, 3, and 6 months following the intervention. RESULTS: NRS and WOMAC scores improved at all time points. Mean pain intensity improved from 7.2 (95% confidence interval [CI]: 6.8 to 7.7) at baseline to 4.2 (95%CI: 3.5 to 5.0) at 6-month follow-up (P < 0.001). Composite WOMAC score improved from 48.7 (95%CI: 43.3 to 54.2) at baseline to 20.7 (95%CI: 16.6 to 24.7) at 6-month follow-up (P < 0.001). Adverse events did not persist beyond 1 month and included local pain, hypoesthesia, swelling, and bruise. CONCLUSION: Chemical neurolysis of genicular nerves with phenol provided efficacious analgesia and functional improvement for at least 6 months in most patients with a low incidence of adverse effects.

Chemical Hip Denervation for Inoperable Hip Fracture.

BACKGROUND: Hip fracture is a challenging geriatric problem for the health care professionals, especially in patients with multiple comorbidities. In patients with inoperable hip fracture secondary to severe comorbid conditions, the pain can lead to significant challenges in nursing care. With the current understanding of the innervation of hip joint, we are now able to perform selective chemical denervation of the articular branches of femoral and obturator nerves to manage the pain associated with inoperable hip fracture. METHODS: In this retrospective case series, we analyzed 20 consecutive patients with inoperable hip fracture who received chemical denervation and examined the effect of the denervation on pain and functional outcomes, including the maximally tolerable hip flexion and the ability to sit during their hospital stay. We also assessed the likelihood of being ambulatory as a long-term outcome. RESULTS: The movement-related pain was significantly reduced at 10 minutes postprocedure, on postintervention days 1 and 5 (P values of <.001), and the degree of maximally tolerable hip flexion was doubled at the same time points (P values of <.001, .003, and .002, respectively). Fifty percent of the patients managed to sit within the first 5 days after procedure, and 3 of them managed to walk with aid 4 months after hip denervation. No procedural adverse event was noted. CONCLUSIONS: We concluded that this chemical hip denervation could be a safe and effective measure to handle the pain-related and rehabilitation-related challenges as a result of inoperable hip fracture.

A magnetic resonance imaging study of local anesthetic spread in patients receiving an erector spinae plane block.

PURPOSE: Despite the popularity of the erector spinae plane (ESP) block, both the mechanism of the block and the extent of injectate spread is unclear. This study used magnetic resonance imaging (MRI) to evaluate the spread of local anesthetic injectate following ESP blocks in six patients with pain. METHODS: Six patients received a left-sided ultrasound-guided ESP block at the T10 level. The injectate contained 29.7 mL of 0.25% bupivacaine and 0.3 mL of gadolinium in the first patient, with an additional 5 mL (50 mg) of triamcinolone in the subsequent five patients. Sensory block to pinprick and cold as well as pain score (with 0 indicating no pain and 10 being maximum pain) were assessed 20 and 30 min respectively following the ESP block. MRI was performed one hour after the block. RESULT: The injectate spread into the intercostal space and neural foramina in all six patients, but the extent of cephalocaudal spread was variable, with a median [interquartile range] spread of 9 [5-11] and 3 [2-6] levels for the intercostal space and neural foramina, respectively. The injectate also spread extensively within the erector spinae muscles. Spread to the epidural space was seen in two patients. Sensory block was achieved in both ventral and dorsal dermatomes in all patients, though the extent was variable. CONCLUSIONS: Our study showed that the ESP block injectate consistently spread to the erector spinae muscles, neural foramina, and intercostal space. It was associated with sensory changes and pain relief in the dorsal and ventral thoracic and abdominal walls. Nevertheless, the extent of spread to the neural foramina and intercostal space, and the sensory block itself, was highly variable.

RéSUMé: OBJECTIF: Malgré la popularité du bloc plan des érecteurs du rachis (PER), le mécanisme du bloc et l'ampleur de la diffusion du produit injecté ne sont pas clairement connus. Cette étude a utilisé l'imagerie par résonance magnétique (IRM) pour évaluer la diffusion de l'anesthésique local injecté après des blocs du PER chez six patients présentant des douleurs. MéTHODES: Six patients ont reçu un bloc du PER guidé par échographie du côté gauche au niveau T10. Le produit injecté contenait 29,7 mL de bupivacaïne 0,25 % et 0,3 mL de gadolinium pour le premier patient avec un supplément de 5 mL (50 mg) de triamcinolone pour les cinq patients suivants. Le bloc sensitif au toucher/piquer et au froid, ainsi que le score de douleur (où 0 indique une absence de douleur et 10, une douleur maximum) ont été évalués respectivement 20 et 30 minutes après le bloc du PER. Une IRM a été réalisée une heure après le bloc. RéSULTAT: Le produit injecté a diffusé dans l'espace intercostal et les foramens intervertébraux chez les six patients, mais l'étendue de la diffusion céphalocaudale a été variable avec une diffusion médiane [plage interquartile] de 9 [5 à 11] niveaux pour les espaces intercostaux et 3 [2 à 6] niveaux pour les foramens intervertébraux. Le produit injecté a également largement diffusé dans les muscles érecteurs du rachis. Une diffusion vers l'espace épidural a été observée chez deux patients. Un bloc sensitif des dermatomes ventraux et dorsaux a été obtenu chez tous les patients, bien que son étendue ait été variable. CONCLUSIONS: Notre étude a montré que le produit injecté dans un bloc du PER diffusait constamment dans les muscles érecteurs du rachis, les foramens intervertébraux et les espaces intercostaux. Il a été associé à des modifications sensorielles et à un soulagement de la douleur dans les parois thoraciques et abdominales, ventrales et dorsales. Néanmoins, l'étendue de la diffusion vers les foramens intervertébraux et les espaces intercostaux, ainsi que le bloc sensitif proprement dit ont été très variables.

Perioperative Pain and Addiction Interdisciplinary Network (PAIN) clinical practice advisory for perioperative management of buprenorphine: results of a modified Delphi process.

Until recently, the belief that adequate pain management was not achievable while patients remained on buprenorphine was the impetus for the perioperative discontinuation of buprenorphine. We aimed to use an expert consensus Delphi-based survey technique to 1) specify the need for perioperative guidelines in this context and 2) offer a set of recommendations for the perioperative management of these patients. The major recommendation of this practice advisory is to continue buprenorphine therapy in the perioperative period. It is rarely appropriate to reduce the buprenorphine dose irrespective of indication or formulation. If analgesia is inadequate after optimisation of adjunct analgesic therapies, we recommend initiating a full mu agonist while continuing buprenorphine at some dose. The panel believes that before operation, physicians must distinguish between buprenorphine use for chronic pain (weaning/conversion from long-term high-dose opioids) and opioid use disorder (OUD) as the primary indication for buprenorphine therapy. Patients should ideally be discharged on buprenorphine, although not necessarily at their preoperative dose. Depending on analgesic requirements, they may be discharged on a full mu agonist. Overall, long-term buprenorphine treatment retention and harm reduction must be considered during the perioperative period when OUD is a primary diagnosis. The authors recognise that inter-patient variability will require some individualisation of clinical practice advisories. Clinical practice advisories are largely based on lower classes of evidence (level 4, level 5). Further research is required in order to implement meaningful changes in practitioner behaviour for this patient group.

The perioperative patient on buprenorphine: a systematic review of perioperative management strategies and patient outcomes.

BACKGROUND: An increasing number of patients with opioid use disorder (OUD) are treated with opioid agonist-antagonists such as buprenorphine/naloxone. Perioperative management of patients on buprenorphine/naloxone is inconsistent and remains a controversial topic with mismanagement posing a significant risk to the long-term health of these patients. METHODS: We performed a systematic literature search involving Medline, Medline In-Process, Embase, Cochrane Central, Cochrane Database of Systematic Reviews, PsycINFO, Web of Science (Clarivate), Scopus (Elsevier), CINAHL (EbscoHosst), and PubMed (NLM). RESULTS: Eighteen studies were included in the final sample, including one controlled study and four observational studies . Neither the controlled study nor the observational studies assessed addiction treatment retention, harm reduction, or long-term mortality rates as primary or secondary outcomes. Of the observational studies, authors showed equivalent peri- and postoperative pain control among buprenorphine continued patients. All but one authors described adequate analgesia among the case reports in which buprenorphine ≤ 16 mg sublingually (SL) daily was continued during the perioperative period. Long-term harm reduction was not reported with only three case reports including any long-term abstinence or relapse rates. CONCLUSIONS: The current understanding of the risks and benefits of continuing or stopping buprenorphine perioperatively is limited by a lack of high-quality evidence. Observational studies and case reports indicate no evidence against continuing buprenorphine perioperatively, especially when the dose is < 16 mg SL daily. In patients with significant potential for relapse, such as those with a recent history of OUD, the discontinuation of buprenorphine should have a strong rationale supported by patient and surgical preferences. Future studies require standardized reporting of median doses, details on the route of delivery, dosing schedules and any dosing changes, and rates of addiction relapse, including long-term morbidity and mortality where possible.

RéSUMé: CONTEXTE: Un nombre croissant de patients présentant un trouble d'utilisation des opioïdes (TUO) sont traités avec des agonistes/antagonistes des opioïdes, tels que la buprénorphine et la naloxone. La gestion périopératoire des patients sous buprénorphine/naloxone n'est pas constante et reste un sujet de controverses; de plus une mauvaise gestion pose un risque significatif pour la santé à long terme de ces patients. MéTHODES: Nous avons effectué une recherche systématique de la littérature dans les bases de données suivantes : Medline, Medline In-Process, Embase, Cochrane Central, Cochrane Database of Systematic Reviews, PsycINFO, Web of Science (Clarivate), Scopus (Elsevier), CINAHL (EbscoHosst) et PubMed (NLM). RéSULTATS: Dix-huit études ont été incluses dans l'échantillon final, y compris une étude contrôlée et quatre études observationnelles. Ni l'étude contrôlée ni les études observationnelles n'ont évalué la continuation du traitement de l'addiction, la réduction des préjudices infligés ou les taux de mortalité à long terme parmi les critères d'évaluation principaux ou secondaires. Dans les études observationnelles, les auteurs ont montré qu'il y avait un contrôle équivalent de la douleur en péri- et postopératoire chez les patients continuant à recevoir de la buprénorphine. Tous les auteurs sauf un ont décrit une analgésie satisfaisante dans les rapports de cas où la buprénorphine sublinguale avec une dose ≤ 16 mg par jour était maintenue pendant la période périopératoire. La réduction des préjudices à long terme n'était pas décrite; seulement trois rapports de cas indiquaient le taux d'abstinence à long terme ou les taux de rechute. CONCLUSIONS: Les connaissances actuelles des risques et avantages de la poursuite ou de l'arrêt de la buprénorphine en période périopératoire sont limitées par le manque de données probantes de grande qualité. Les études observationnelles et les rapports de cas ne fournissent pas de données probantes à l'encontre de la poursuite de la buprénorphine dans la période périopératoire, en particulier quand la dose journalière par voie sublinguale est < 16 mg. Chez les patients présentant un risque significatif de rechute, comme ceux ayant des antécédents récents de TUO, l'arrêt de la buprénorphine devrait être solidement justifié avec le soutien des préférences des patients et des équipes chirurgicales. Les futures études nécessitent une normalisation du rapport des doses médianes, des détails sur les voies d'administration, de la posologie et de sa modification et des taux de rechute, en incluant aussi, chaque fois que possible, les taux de morbidité et mortalité à long terme.

Can recent chronic pain techniques help with acute perioperative pain?

PURPOSE OF REVIEW: This article discussed how the knowledge and technique of a few chronic pain procedures benefited the perioperative clinicians in their care of patients receiving specific orthopaedic surgical procedures. RECENT FINDINGS: Recent emerging interest in hip and knee denervation for chronic pain management secondary to osteoarthritis stimulates publications on the new understanding of hip and knee joint innervation. The improved understanding of the anatomy allows better precision in targeting the articular branches. The procedures for chronic joint pain such as radiofrequency ablation, chemical neurolysis and neuromodulation procedure have recently been applied to the perioperative care in orthopaedic procedures because of the potential long-lasting analgesia, opioid-sparing effect and consequent improvement in physical function and health-related quality of life after surgery. SUMMARY: Despite the widespread use of regional anaesthesia and multimodal analgesia in the perioperative pain management, more than two-third of the patients reported severe postoperative pain. Therefore, other therapeutic strategies used in chronic pain management such as radiofrequency ablation and neuromodulation have been proposed to optimize acute postsurgical pain. The early experience with those techniques is encouraging, and more studies are required to explore the incorporation of these procedures in the perioperative care.

Echo-guided invasive pain therapy: indications and limitations.

PURPOSE OF REVIEW: The purposes of this review are to summarize the advantages and limitations of ultrasound-guided pain interventions, and to illustrate those interventions with peripheral, axial and musculoskeletal pain procedures. RECENT FINDINGS: With the capability of locating the interfascial plane, ultrasonography has led to the emergence of a series of plane blocks for the thoracoabdominal region in the recent decade.Ultrasonography for musculoskeletal procedures has been of growing interest because of the major advantage of direct visualization and scanning of various soft tissues and real-time spread in the injectate, thereby enhancing precision and efficacy, reducing risk of trauma and avoidance of radiation. For spine and intra-articular structures, ultrasonography is complicated by the bony shadow artefact and often deep location of the structure, making acquisition of ultrasound image challenging. Despite these difficulties, there is growing interest in applying ultrasonography for cervical spine and sacroiliac joint procedures. SUMMARY: Pain intervention under ultrasound guidance is particularly valuable in peripheral and musculoskeletal procedures. There is growing interest of its application in cervical spine and sacroiliac joint. More outcome studies are required in the future to make ultrasound-guided pain intervention as the established procedure.

Landmark-Guided and Ultrasound-Guided Approaches for Trochanteric Bursa Injection: A Cadaveric Study.

BACKGROUND: Trochanteric bursa (TB) injection with local anesthetic and corticosteroid is a treatment for patients suffering from greater trochanteric pain syndrome. Both landmark (LM)-guided and ultrasound (US)-guided methods have been used, but their accuracies have not been determined. This study examined the accuracy of these injections with cadaveric dissection. METHODS: Twenty-four hip specimens were randomized to receive TB injections with methylene blue under either LM-guided or US-guided approach. After dissection, the locations of the dye were classified into 3 categories: intrabursal, extrabursal, or combined intrabursal and extrabursal. The presence of dye in the intrabursal space with or without extrabursal leak was considered a successful injection. Accuracy was defined as the percentage of successful injection. RESULTS: The accuracies of the LM-guided and US-guided injection were 0.67 (95% confidence interval 0.35-0.90) and 0.92 (95% confidence interval 0.62-1.00), respectively, with no significant difference. CONCLUSIONS: This is the first cadaveric study examining the accuracy of both the US-guided and LM-guided techniques for TB injection. Future clinical studies are required to compare the outcomes of LM-guided and US-guided greater trochanteric pain syndrome injection.

The future of regional anesthesia education: lessons learned from the surgical specialty.

PURPOSE: Application of ultrasound in regional anesthesia has now become the standard of care and its use has shown to reduce complications. Nevertheless, gaining expertise in ultrasound-guided regional anesthesia requires the acquisition of new cognitive and technical skills. In addition, due to a reduction in resident working hours and enforcement of labour laws and directives across various states and countries, trainees perform and witness fewer procedures. Together, these issues create challenges in the teaching and learning of ultrasound-guided regional anesthesia in the time-based model of learning. PRINCIPAL FINDINGS: The challenges of teaching ultrasound-guided regional anesthesia are similar to those experienced by our surgical counterparts with the advent of minimally invasive surgery. In order to overcome these challenges, our surgical colleagues used theories of surgical skills training, simulation, and the concept of deliberate practice and feedback to shift the paradigm of learning from experience-based to competency-based learning. CONCLUSION: In this narrative review, we describe the theory behind the evolution of surgical skills training. We also outline how we can apply these learning theories and simulation models to a competency-based curriculum for training in ultrasound-guided regional anesthesia.

Comparison of Fluoroscopy and Ultrasound Guidance for Sacroiliac Joint Injection in Patients with Chronic Low Back Pain.

BACKGROUND AND OBJECTIVES: Sacroiliac joint (SIJ) arthritis is a common cause of chronic mechanical low back pain (LBP) that is often treated with injection of local anesthetic and steroids. Ultrasound (US) has emerged as a viable alternative to fluoroscopy (FL) to guide SIJ injections; however, few studies have compared these modalities. In this prospective randomized, controlled trial, we compared both accuracy and efficacy of US and FL guidance for SIJ injections. METHODS: Forty patients with chronic moderate-to-severe LBP secondary to SIJ arthritis were randomized to receive US- or FL-guided unilateral SIJ injections. Primary outcomes included pain at 1 month measured by numerical rating scale (NRS) scores. Secondary outcomes included NRS scores at 24 hours, 72 hours, 1 week, and 3 months after injection, physical functioning at 1 month after the procedure, procedure time, incidence of intra-articular and peri-articular needle placement, patient discomfort, overall patient satisfaction, and daily opioid consumption. RESULTS: There was no significant difference in NRS pain scores between the 2 groups at 1 month or at any other follow-up points. A significant reduction from baseline mean NRS scores was observed in both groups at 1 month after injection (US 22.7%, P = 0.025; FL 37.3%, P < 0.001). There was no significant difference in procedure-related variables, physical functioning, discomfort, opioid utilization, and patient satisfaction between the 2 groups. CONCLUSIONS: Ultrasound-guided SIJ injection with fluoroscopic confirmation has similar accuracy and efficacy to fluoroscopy alone for SIJ injections in patients with chronic low back pain secondary to SIJ arthritis.

Pericapsular nerve group (PENG) block: what have we learned in the last 5 years?

This educational article discusses the current understanding of the pericaspular nerve group block (PENG) of the hip regarding its mechanism of action and spread patterns, as well as plausible explanations for postblock quadriceps weakness. Finally, we will discuss the recent evidence of PENG block as an analgesic block in hip fractures and in different hip surgeries.

Axillary nerve: what anesthesiologists and pain physicians should know.

Innervation of the shoulder joint is complex and remains poorly understood among regional anesthesiologists and chronic pain specialists. Current literature supports the important contribution of the axillary nerve to the total innervation of the shoulder, as well as its blockade for perioperative pain and denervation for chronic shoulder pain. However, a description of the entire course of the axillary nerve, the corresponding optimal targets, and the sonoanatomy pertinent to pain intervention is lacking. This educational article discusses in detail the functional anatomy and sonographic identification of possible windows for axillary nerve intervention. We discuss the contribution, extent, and type of innervation the axillary nerve provides to the shoulder joint, which is often misunderstood. Ultimately, this article serves to stimulate thoughts and ideas for future research in an area where literature is scarce.