Shedding Light on Perioperative Nerve Injury: An Investigation Using the SHED (Symptoms Categorization-History Taking-Examination-Diagnostic Evaluations) Approach.

Peripheral nerve blocks (PNBs) provide analgesia and anesthesia in diverse surgical procedures. Despite their recognized benefits, the occurrence of complications, particularly peripheral nerve injuries (PNIs), is a noteworthy concern. Prompt identification and intervention for perioperative nerve injuries are crucial to prevent permanent neurological impairment. A meticulous, systematic evaluation centered on the onset and progression of symptoms becomes imperative. The SHED (symptoms categorization-history taking-examination-diagnostic evaluations) approach serves as a valuable tool for diagnosing causative factors, determining the type of nerve injury, and formulating an effective treatment plan to mitigate further harm. This case report employs the SHED approach to elucidate a perplexing instance of PNIs. The patient, experiencing neurological symptoms post-forearm surgery under a PNB, serves as a focal point. The report underscores the significance of a systematic, stepwise approach in managing patients with suspected PNIs. Vigilant patient monitoring, collaborative teamwork, shared responsibilities, and consideration of potential contributing factors beyond the nerve block are highlighted for an accurate diagnosis and effective treatment of PNIs. The aim is to guide healthcare professionals in navigating similar clinical scenarios, ultimately ensuring patient safety and optimizing outcomes.

"Knowing It Before Blocking It," the ABCD of the Peripheral Nerves: Part A (Nerve Anatomy and Physiology).

Regional anesthesia (RA) is an interplay between the local anesthetic (LA) solution and the neural structures, resulting in nerve conduction blockade. For that, it is necessary to understand which hurdles the LA has to overcome and which components of the nerves are involved. Background knowledge of the neural and non-neural components of the nerve helps locate the safest area for LA deposition. In addition, knowledge of nerve physiology and the conduction process helps to understand the patterns of block onset, involved fibers, and block regression. Neural connective tissue protects the nerve on the one hand and influences the overall effect of the blockade and the occurrence of nerve injuries on the other. The arrangement of the nerve fibers explains the science behind the differential blockage after LA deposition. This article describes the important aspects of nerve anatomy (nerve formation and composition) and nerve physiology (impulse generation and propagation). It also provides insight into the physiological processes involved when a damaged neural structure leads to potential clinical symptoms. It will help readers sharpen their skills and knowledge to execute safe RA without damaging any vital structures in the nerve.

Ultrasound-Guided CAPS (Crosswise Approach to Popliteal Sciatic) Block: A Novel Technique for Supine Popliteal Fossa Block.

The sciatic nerve block in the popliteal fossa is a popular lower extremity block for below-knee surgeries. Here the sciatic nerve is targated at or just above the point of its divergence into the tibial and common peroneal nerves. Amongst the described techniques, the supine approach of popliteal fossa block offers greatest patient comfort but has a few challenges accessing the nerve. We describe a novel ultrasound-guided distal transverse or crosswise approach to popliteal sciatic (CAPS) block performed in five patients in the supine position without unsteadiness of the knee or hip joint.

Transient paraplegia due to accidental intrathecal bupivacaine infiltration following pre-emptive analgesia in a patient with missed sacral dural ectasia.

STUDY DESIGN: A case report with review of the literature. OBJECTIVE: To highlight the need for careful magnetic resonance imaging evaluation for the presence of incidental lumbosacral dural anomalies before attempting caudal epidural interventions. SUMMARY OF BACKGROUND DATA: Pre-emptive analgesia through the caudal epidural route provides good postoperative pain relief in spine surgeries. Several precautions have been advised in the literature. Presence of sacral-dural ectasia should be considered a relative contraindication for this procedure. METHODS: A 50-year old woman underwent posterior instrumented spinal fusion for L4-L5 spondylolisthesis under general anesthesia. She received single shot caudal epidural analgesia at the start of the procedure. RESULTS: After complete emergence from anesthesia, she had complete motor and sensory loss below the T12 spinal level, which reversed to normal neurology in 6 hours. Retrospective evaluation of the patient's magnetic resonance imaging showed an ectatic, low lying lumbosacral dural sac which had been overlooked in the initial evaluation. The drugs given by the caudal route have been accidentally administered into the thecal sac causing a brief period of neurologic deficit. CONCLUSION: This unexpected complication has been reported only in the pediatric literature before. It is important to look for the presence of lumbosacral dural anomalies before planning caudal epidural injections in adults also. Sacral dural ectasia and other lumbosacral anomalies must be recognized as contraindications for caudal epidural pre-emptive analgesia for spine surgery. Other modes of postoperative pain relief should be tried in these patients.