Neurological complication analysis of 1000 ultrasound guided peripheral nerve blocks for elective orthopaedic surgery: a prospective study

Short-term complications of anesthetic technique used in hip fracture surgery in elderly people

Postoperative complications of fracture are one of the main problems in older patients with hip fracture. In this study, complications were observed 48 hours after surgery in different anesthetic procedures. This prospective cross sectional study was carried out over a 12-month period. All subjects over 55 years of age undergoing hip fracture surgery were selected for study with ASA class (American Society of Anesthesiology: one, two and three). After determining the vital signs in the operating room, anesthesia type (general, spinal and epidural) and various variables were recorded. It was observed that the spinal anesthesia method had the lowest level of postoperative disturbances of consciousness and had the shortest duration in terms of duration of time. On the other hand, general anesthesia was the least in terms of blood transfusion. Finally, epidural anesthetic method showed the least amount of pain 48 hours after operation and the least changes in blood pressure and heart rate.

The Incidence of Complications Is Low Following Foot and Ankle Surgery for Which Peripheral Nerve Blocks Are Used for Postoperative Pain Management

BACKGROUND

The incidence of neurologic complications from foot and ankle surgery utilizing regional anesthesia is not well established.

QUESTIONS/PURPOSES

The purpose of this study was to prospectively determine the incidence of neurologic and peripheral nerve block (PNB) site complications on a busy foot and ankle service that utilizes ankle blocks (ABs) and popliteal blocks (POPs).

PATIENTS AND METHODS

This prospective observational study included patients undergoing foot and ankle surgery with ABs or POPs. Block choice was determined by surgeon's preference. Patients were assessed for complications during postoperative visits at 2, 6, and 12 weeks. The relation of each complication to the block was scored by a surgeon and anesthesiologist.

RESULTS

From October 2012 to October 2014, 2516 patients underwent 2704 surgeries. There were 195 complications (7.2%) considered neurologic or at the PNB site. The incidence of serious complications was 0.7%. A higher complication rate was reported for POPs (8.8%) than for ABs (2.5%). However, when analysis was limited to forefoot surgery, this difference was not significant. Dexamethasone use was associated with increased complications for POPs. Only 5 of the 195 total complications, and 2 of 20 serious complications, were deemed to have been likely caused by the block by both the surgeon and anesthesiologist reviewer.

CONCLUSIONS

The incidences of neurologic or block-related complications and serious complications were 7.2 and 0.7%, respectively, most without a clear surgical vs. nerve block etiology. The higher complication rate for POPs using perineural dexamethasone should be interpreted cautiously in light of the lack of randomization and likely confounders.

Comparison of Time to Operation and Efficacies of Ultrasound-Guided Nerve Block and General Anesthesia in Emergency External Fixation of Lower Leg Fractures (AO 42, 43, 44)

The present randomized controlled trial evaluated the usefulness of ultrasound (US)-guided nerve block (NB) for emergency external fixation of lower leg fractures, by investigating the time required before surgery and the clinical results stratified by the anesthesia method (US-guided NB or general anesthesia [GA]). From June 2014 to April 2016, 40 patients who had undergone emergency surgery for external fixator application were enrolled in the present study. We measured the lead time before the start of surgery after the decision to perform emergency surgery in both groups. The US-guided NB group included 17 males (85%) and 3 females (15%), with a mean age of 55.6 (range 33 to 77) years. Of these 20 patients, 12 (60%) had comorbidities such as diabetes mellitus, hypertension, and kidney-related disease. Fracture type 42, 43, and 44 in the AO classification were observed in 3 (15%), 12 (60%), and 5 (25%) cases, respectively. The mean interval before emergency surgery was 4.3 (range 2 to 6.25) hours in the US-guided NB group. In the GA group (n = 20 patients), the mean interval before emergency surgery was 9.4 (range 3 to 14) hours, and this difference was statistically significant (p < .001). In the US-guided NB group, no cases of anesthesia failure or unstable vital signs occurred during surgery. Also, no postoperative complications related to the anesthesia method, such as aggravation of the general condition, developed. In contrast, 1 case of postoperative atelectasis occurred in the GA group. Emergency external fixation with US-guided NB in patients with lower extremity trauma can be implemented in less time, regardless of the preoperative preparation, which is a requirement for GA.

Complications After Multiple-Site Peripheral Nerve Blocks for Foot and Ankle Surgery Compared With Popliteal Sciatic Nerve Block Alone

BACKGROUND

Single or combined multiple-site peripheral nerve blocks (PNBs) are becoming popular for patients undergoing surgery on their feet or ankles. These procedures are known to be generally safe in surgical settings compared with other forms of anesthesia, such as spinal block. The purposes of this study were to assess the incidence of complications after the administration of multiple PNBs for foot and ankle surgery and to compare the rates of complications between patients who received a single PNB and those who received multiple blocks.

METHODS

Charts were reviewed retrospectively to assess peri- and postoperative complications possibly related to the PNBs. The records of 827 patients who had received sciatic nerve blocks, femoral nerve blocks adductor canal blocks, or combinations of these for foot and/or ankle surgery were analyzed for complications. The collected data consisted of age, sex, body mass index, presence of diabetes mellitus, smoking history, tourniquet time, and complications both immediately postoperatively and 1 year later.

RESULTS

Of these 827 patients, 92 (11.1%) developed neurologic symptoms after surgery; 22 (2.7%) of these likely resulted from the nerve blocks, and 7 (0.8%) of these were unresolved after the patients' last follow-up visits. There were no differences in complication rates between combined blocks and single sciatic nerve blocks.

CONCLUSION

There were more complications, both transient and long term, after anesthetic PNBs than previous literature has reported. Combined multiple-site blocks did not increase the rate of neurologic complications.

LEVEL OF EVIDENCE

Level III, retrospective comparative study.

Advances in Experimental Medicine and Biology: Intrafascicular Local Anesthetic Injection Damages Peripheral Nerve-Induced Neuropathic Pain

Peripheral nerve blockade (PNB) is advantageous for patients undergoing surgery to decrease the perioperative opioid consumptions and enhance recovery after surgery.Inadvertent local anesthetic (LA) administration into nerve fiber intrafascicularly easily results in unrecognized nerve injury. Using nerve block guidance either by ultrasound, electrical nerve stimulator, or using pressure devices does not prevent nerve damage, even though most of the nerve injury is transiently. The incidence of neurologic symptoms or neuropathy is in the range of 0.02-2.2%, and no significant difference of postoperative neurologic symptoms is found as compared with using ultrasound or guided nerve stimulator technique. However, intrafascicular lidocaine brought about macrophage migration into the damaged fascicle, Schwann cell proliferation, increased intensity of myelin basic protein, and shorten withdrawal time to mechanical stimuli. In dorsal root ganglion (DRG), intrafascicular LA injection increased the activated transcriptional factor 3 (ATF-3) and downregulated Nav1.8 (Nav1.8). In spinal dorsal horn (SDH), the microglia and astrocytes located in SDH were activated and proliferated after intrafascicular LA injection and returned to baseline gradually at the end of the month. This is a kind of neuropathic pain, so low injection pressure should be maintained, the correct needle bevel used, nerve stimulator or ultrasound guidance applied, and careful and deliberately slow injection employed as important parts of the injection technique to prevent intrafascicular LA administration-induced neuropathic pain.

Clinical effects of single femoral nerve block in combination with general anesthesia on geriatric patients receiving total knee arthroplasty

Objective:

To evaluate the clinical effects of single femoral nerve block (sFNB) combined with general anesthesia on geriatric patients receiving unilateral total knee arthroplasty (UTKA).

Methods:

Sixty geriatric UTKA patients who were treated in The First People's Hospital of Changzhou from January 2015 to August 2015 were randomly divided into an sFNB + laryngeal mask airway (FLA) group, an sFNB + tracheal intubation (FGA) group and a tracheal intubation (GA) group. Their clinical parameters and indices were recorded. They were scored by the Visual Analogue Scale (VAS).

Results:

All patients completed this study. FLA and FGA groups used less propofol, remifentanil and fentanyl than GA group (P<0.01), with shorter recovery time and extubation time (P<0.05). Compared to GA group, FLA and FGA groups had lower systolic blood pressures at T3, T4 and T5 (P<0.05), and lower heart rates at T5 (P<0.05). FLA and FGA groups had fewer cases of adverse reactions after extubation (P<0.01). FLA group was less prone to irritating cough after extubation and pharyngeal pain than FGA and GA groups (P<0.01). The postoperative six hour and 24 hour VAS scores in resting state as well as the postoperative 24 hour and 48 hour scores in training state of FLA and FGA groups were lower than those of GA group (P<0.05). FLA and FGA groups used significantly lower times and total doses of patient-controlled intravenous analgesia pump.

Conclusion:

sFNB combined with general anesthesia, especially that using laryngeal mask, were superior to general anesthesia alone, which reduced recovery and extubation times, and decreased intraoperative and postoperative drug uses, postoperative early VAS score and adverse reactions.

Neurologic complications of shoulder joint replacement

BACKGROUND

Little attention has been given to neurologic complications after shoulder joint replacement (SJR). Previously thought to occur infrequently, it is likely that many are not clinically recognized, and they can result in postoperative morbidity and impair the patient's recovery. The purpose of this study was to document the prevalence of nerve complications after SJR, to identify the nerves involved, and to define patient outcomes.

METHODS

This was a retrospective review of 211 SJRs in 202 patients during a 5-year period were included, with 89 male and 122 female patients at an average age of 70 years. All patients underwent a comprehensive analysis of any postoperative nerve complication, including onset, duration, investigation, treatment, and symptom resolution.

RESULTS

Of the 211 SJR procedures, 44 were identified as having sustained a nerve complication (20.9%), with 36 female (81.8%) and 8 male patients (18.2%). Reverse SJR was associated with the highest number of nerve complications. The median nerve (25 patients) and musculocutaneous nerve (8 patients) were most commonly involved. Most nerve complications were transient and resolved within 6 months. Permanent sequelae and injuries that required secondary surgical intervention were rare.

CONCLUSION

The occurrence of nerve complications after SJR is common, but almost all will fully recover. Most are transient neurapraxias involving the lateral cord of the brachial plexus. Women are more likely to be affected, as are patients who have undergone prior surgery to the affected shoulder. Most are likely to be the result of excessive traction or direct injury to the nerves during glenoid exposure.

Evaluation of analgesic regimens in total knee arthroplasty, retrospective study

OBJECTIVE:

Analgesic therapies have an immense role in early rehabilitation period after total knee arthroplasty (TKA) and multimodal approaches should be considered as the first choice of treatment. In this retrospective study, the aim was to evaluate the effectiveness of multimodal analgesic therapies for TKA, including femoral nerve block (FNB) and patient controlled analgesia (PCA).

METHODS:

The data of 79 patients who underwent TKA between January and December 2016 were retrospectively evaluated. In all, 63 patients met the inclusion criteria. Hemodynamic records and Visual Analogue Scale (VAS) pain scores for postoperative 0, 2, 4, 6, 9, and 12 hours were evaluated and patients were separated into 3 groups. Group 1: FNB with 0.25% bupivacaine, Group 2: FNB with 0.166% bupivacaine, and Group 3: No FNB.

RESULTS:

The average age of the patients was 64.3±14.9 years and average body mass index (BMI) was 32.5±5.3 kg/m². There was no statistical difference between groups in age, gender, American Society of Anesthesiologists (ASA) classification of physical health scores, BMI, or anesthesia type (p<0.05). When VAS scores at postoperative time intervals were compared, there was a statistically significant difference between Group 1 and Group 2 (p>0.05). When difference between Groups 1 and 3 and Groups 2 and 3 were compared, the difference was statistically significant for VAS 0 (p>0.05). Additional analgesic use was highest in Group 3.

CONCLUSION:

This study demonstrated that FNB significantly decreases postoperative pain intensity and additional analgesia requirement in patients undergoing TKA. A concentration of 0.166% bupivacaine is as effective as a concentration of 0.25% when used as part of a multimodal analgesia regimen in TKA.

Pain and Opioid Use After Total Shoulder Arthroplasty With Injectable Liposomal Bupivacaine Versus Interscalene Block

Postoperative pain control is a significant concern after total shoulder arthroplasty. Injectable periarticular liposomal bupivacaine, which has been found to decrease opioid use after orthopedic procedures, has been proposed as a viable alternative to regional anesthesia. This study compared the efficacy of liposomal bupivacaine vs interscalene block among patients undergoing total shoulder arthroplasty. A retrospective review was conducted of 79 patients who underwent anatomic total shoulder arthroplasty performed by a single surgeon between January 2013 and April 2015. Patient demographics, in-hospital Numeric Pain Rating Scale (NPRS) score obtained at 12-hour intervals, length of stay, and total in-hospital morphine equivalents in both the bupivacaine (n=25) and block (n=44) groups were recorded. Differences in length of stay, morphine equivalents, and age were assessed with Wilcoxon tests. Sex differences were assessed with the chi-square test. Repeated measures analysis with least square means was used to assess longitudinal changes in NPRS scores. No significant differences were found between groups for sex (P=.89), age (P=.81), American Society of Anesthesiologists classification (P=.50), preoperative opioid use (P=.41), length of stay (P=.32), or morphine equivalents (P=.71). The average NPRS score in the first 12 hours was 3.01 for the bupivacaine group and 4.41 for the interscalene block group (P=.25). By 48 hours postoperatively, average NPRS scores were similar (P=.93) for the 2 groups, 4.90 for the bupivacaine group and 4.19 for the interscalene block group. The findings for this cohort of patients undergoing anatomic total shoulder arthroplasty showed no significant difference for pain scores, postoperative narcotic use, or length of stay with injectable liposomal bupivacaine vs interscalene block. [Orthopedics. 2017; 40(5):e806-e811.].

Brachial Plexus Blockade Causes Subclinical Neuropathy: A Prospective Observational Study

Background: The objective of this study is to determine subclinical changes in hand sensation after brachial plexus blocks used for hand surgery procedures. We used Semmes-Weinstein monofilament testing to detect these changes. We hypothesized that patients undergoing brachial plexus nerve blocks would have postoperative subclinical neuropathy detected by monofilament testing when compared with controls. Methods: In total, 115 hand surgery adult patients were prospectively enrolled in this study. All patients undergoing nerve-related procedures were excluded as well as any patients with preoperative clinically apparent nerve deficits. Eighty-four patients underwent brachial plexus blockade preoperatively, and 31 patients underwent general anesthesia (GA). Semmes-Weinstein monofilament testing of the hand was performed preoperatively on both the operative and nonoperative extremities and postoperatively at a mean of 11 days on both hands. Preoperative and postoperative monofilament testing scores were compared between the block hand and the nonoperated hand of the same patient, as well as between the block hands and the GA-operated hands. Results: There were no recorded clinically relevant neurologic complications in the block group or GA group. A statistically significant decrease in sensation in postoperative testing in the operated block hand compared with the nonoperated hand was noted. When comparing the operated block hand with the operated GA hand, there was a decrease in postoperative sensation in the operated block hand that did not reach statistical significance. Conclusions: Brachial plexus blockade causes subtle subclinical decreases in sensibility at short-term follow-up, without any clinically relevant manifestations.

Anatomical study of the articular branch of the lateral pectoral nerve to the shoulder joint

PURPOSE

The purpose of this study was to document the distribution of the articular branch of the lateral pectoral nerve (LPN) to the shoulder and to identify a suitable point for its blockade.

METHODS

This study involved the dissection of 43 shoulders of 22 unembalmed cadavers (6 male and 16 female) to identify the LPN and its articular branch to the shoulder. To identify the suitable anatomical point for blocking the articular branch of the LPN, several anatomical landmarks around the shoulder were measured.

RESULTS

The articular branch of the LPN to the shoulder was present in 29 of 43 cases (67.4 %). The appropriate point to block the articular branch of the LPN was identified at a mean distance of 1.5 cm below the clavicle, on the line connecting the closest points between the clavicle and the coracoid process, and at a mean depth of 1.0 cm from the skin.

CONCLUSION

The articular branch of the LPN to the shoulder, as well as the muscular and cutaneous branches of the LPN, covers a portion of the shoulder joint with suprascapular and axillary nerves. Surgeons might consider a peripheral block of the suprascapular, axillary, and LPNs to provide maximum block coverage after shoulder joint surgery.

Suprascapular Nerve Block Versus Interscalene Block as Analgesia After Arthroscopic Rotator Cuff Repair: A Randomized Controlled Noninferiority Trial

PURPOSE

To compare the efficacy of suprascapular nerve block (SSB) and interscalene block (ISB) as postoperative analgesia within the first 24 hours after arthroscopic supraspinatus and/or infraspinatus tendon repair.

METHODS

A single-blind, randomized controlled study was performed between 2013 and 2014. The inclusion criteria were arthroscopic supraspinatus and/or infraspinatus tendon repair confirmed intraoperatively, with or without associated procedures, and informed consent. The exclusion criteria were a previously operated shoulder, repair of the subscapularis tendon, and an allergy to local anesthetics. ISB was performed under ultrasound guidance by an anesthesiologist, whereas SSB was performed based on specific anatomic landmarks by a surgeon. The primary evaluation criterion was mean shoulder pain score during the first postoperative 24 hours assessed on a visual analog scale by the patient. The secondary criteria were complications of locoregional anesthesia, the use of analgesics in the recovery room (the first 2 hours) until postoperative day 7, and pain (visual analog scale) during the first week. Forty-four patients were needed for this noninferiority study. An institutional review board approved the study.

RESULTS

Seventy-four patients were randomized, and 59 met the intraoperative inclusion criteria. Six patients were excluded (1 for pneumothorax after ISB, 1 for unsuccessful SSB, and 4 for incomplete questionnaires). None of the patients were lost to follow-up. There was no significant difference between the SSB and ISB groups in mean pain score for the first 24 hours (P = .92) or the first 7 days (P = .05). However, there was significantly less pain in the ISB group in the recovery room (P = .01). Consumption of analgesics was comparable between the groups, but the SSB group took significantly more morphine in the recovery room.

CONCLUSIONS

In this prospective, randomized controlled study, SSB was as effective as ISB for mean pain control within the first 24 hours but ISB was more effective in relieving pain in the recovery room after arthroscopic supraspinatus and/or infraspinatus tendon repair.

LEVEL OF EVIDENCE

Level I, therapeutic, randomized controlled study.

Regional anesthesia practice in China: a survey

STUDY OBJECTIVE

Neuraxial anesthesia has been widely used in China. Recently, Chinese anesthesiologists have applied nerve stimulator and ultrasound guidance for peripheral nerve blocks. Nationwide surveys about regional anesthesia practices in China are lacking. We surveyed Chinese anesthesiologists about regional anesthesia techniques, preference, drug selections, complications, and treatments.

DESIGN

A survey was sent to all anesthesiologist members by WeChat. The respondents can choose mobile device or desktop to complete the survey. Each IP address is allowed to complete the survey once.

MAIN RESULTS

A total of 6589 members read invitations. A total of 2654 responses were received with fully completed questionnaires, which represented an overall response rate of 40%. Forty-one percent of the respondents reported that more than 50% of surgeries in their hospitals were done under regional anesthesia. Most of the participants used test dose after epidural catheter insertion. The most common drug for test dose was 3-mL 1.5% lidocaine; 2.6% of the participants reported that they had treated a patient with epidural hematoma after neuraxial anesthesia. Most anesthesiologists (68.2%) performed peripheral nerve blocks as blind procedures based on the knowledge of anatomical landmarks. A majority of hospitals (80%) did not stock Intralipid; 61% of the respondents did not receive peripheral nerve block training.

CONCLUSIONS

The current survey can serve as a benchmark for future comparisons and evaluation of regional anesthesia practices in China. This survey revealed potential regional anesthesia safety issues in China.

Will the Real Benefits of Single-Shot Interscalene Block Please Stand Up? A Systematic Review and Meta-Analysis

BACKGROUND

Interscalene block (ISB) can provide pain relief after shoulder surgery, but a reliable quantification of its analgesic benefits is lacking. This meta-analysis examines the effect of single-shot ISB on analgesic outcomes during the first 48 hours after shoulder surgery.

METHODS

We retrieved randomized and quasirandomized controlled trials examining the analgesic benefits of ISB compared with none in shoulder surgery. Severity of postoperative pain measured on a visual analog scale (10 cm scale, 0 = no pain, 10 = worst pain) at rest at 24 hours was the designated primary outcome. Secondary outcomes included pain severity at rest and with motion at 2, 4, 6, 8, 12, 16, 32, 36, 40, and 48 hours postoperatively. Opioid consumption, postoperative nausea and vomiting, patient satisfaction with pain relief, and postanesthesia care unit and hospital discharge time were also assessed.

RESULTS

A total of 23 randomized controlled trials, including 1090 patients, were analyzed. Patients in the ISB group had more severe postoperative pain at rest by a weighed mean difference (95% confidence interval) of 0.96 cm (0.08-1.83; P = 0.03) at 24 hours compared with no ISB, but there was no difference in pain severity beyond that point. The duration of pain relief at rest and with motion after ISB were 8 and 6 hours, respectively, with a corresponding weighed mean difference in visual analog scale pain scores (99% confidence interval) of -1.59 cm (-2.60 to -0.58) and -2.20 cm (-4.34 to -0.06), respectively, with no additional pain relief benefits beyond these points. ISB reduced postoperative opioid consumption up to 12 hours, decreased postoperative nausea and vomiting at 24 hours, and expedited postanesthesia care unit and hospital discharge. The type, dose, and volume of local anesthetic used did not affect the results.

CONCLUSIONS

ISB can provide effective analgesia up to 6 hours with motion and 8 hours at rest after shoulder surgery, with no demonstrable benefits thereafter. Patients who receive an ISB can suffer rebound pain at 24 hours but later experience similar pain severity compared with those who do not receive an ISB. ISB can also provide an opioid-sparing effect and reduce opioid-related side effects in the first 12 and 24 hours postoperatively, respectively. These findings are useful to inform preoperative risk-benefit discussions regarding ISB for shoulder surgery.

Comparison of Outside Versus Inside Brachial Plexus Sheath Injection for Ultrasound-Guided Interscalene Nerve Blocks

OBJECTIVES

Ultrasound-guided interscalene brachial plexus blocks are commonly used to provide anesthesia for the shoulder and proximal upper extremity. Some reviews identify a sheath that envelops the brachial plexus as a potential tissue plane target, and current editorials in the literature highlight the need to establish precise and reproducible injection targets under ultrasound guidance. We hypothesize that an injection of a local anesthetic inside the brachial plexus sheath during ultrasound-guided interscalene nerve blocks will result in enhanced procedure success and provide a consistent tissue plane target for this approach with a reproducible and characteristic local anesthetic spread pattern.

METHODS

Sixty patients scheduled for shoulder surgery with a preoperative interscalene block for postoperative pain management were enrolled in this prospective randomized observer-blinded study. Each patient was randomly assigned to receive a single-shot interscalene block either inside or outside the brachial plexus sheath.

RESULTS

The rate of complete motor and sensory blocks of the axillary nerve territory 10 minutes after local anesthetic injection for the inside group was 70% versus 37% for the outside group (P < .05). At all measurement intervals beyond 10 minutes, however, neither group showed a statistically significant difference in complete sensory blockade. The incidence rates of transient paresthesia during needle passage were 6.7% for the outside group and 96.7% for the inside group (P < .05).

CONCLUSIONS

Except for faster onset, this prospective randomized trial did not find any advantages to performing an interscalene block inside the brachial plexus sheath. There was a higher incidence of transient paresthesia when injections were performed inside compared to outside the sheath.

Improving total knee arthroplasty perioperative pain management using a periarticular injection with bupivacaine liposomal suspension

Patients undergoing total knee arthroplasty (TKA) report low satisfaction with postoperative pain control. The purpose of this study is to examine if there is a difference in post-operative pain for TKA patients without femoral nerve block receiving an intra-operative pericapsular injection of bupivacaine liposome suspension (EXPAREL; Pacira Pharmaceuticals, Inc., San Diego, California) versus a concentrated multi drug cocktail. Seventy TKA patients were randomly assigned to either the bupivacaine liposome or the multi-drug cocktail. Post-operative pain scores, morphine sulfate equivalence consumption values, adverse events, and overall pain control satisfaction scores were collected. Patients reported significantly higher pain level for the cocktail group on post-op day 1 (p < .05) and post-op day 2 (p < .01) versus the bupivacaine liposome group. This same trend was found for morphine sulfate equivalence consumption in the PACU (p < .01) and post-op day 2 (p < .01). Higher satisfaction in pain control (p < .001) and overall experience (p < .01) was also found in the bupivacaine liposome group. Finally, significantly more adverse events were found in the multi-drug group versus the bupivacaine liposome group (p < .05). The study findings demonstrated a non-inferior difference, albeit not a clinically significant difference, in patient-perceived pain scores, morphine sulfate equivalence consumption, adverse events, and overall satisfaction.

Comparison Between Ultrasonography-Guided Popliteal Sciatic Nerve Block and Spinal Anesthesia for Hallux Valgus Repair

BACKGROUND

We aimed to compare the efficacy, postoperative pain scores, adverse effects, additional analgesic requirements, and patient satisfaction scores of ultrasonography-guided sciatic nerve block by popliteal approach with spinal anesthesia for hallux valgus correction surgery.

METHODS

Sixty patients scheduled for hallux valgus correction surgery were enrolled in this prospective randomized study. Unilateral spinal block was performed on patients in the spinal anesthesia group. Popliteal block group patients received popliteal sciatic nerve block with guidance by both nerve stimulator and ultrasonography. Durations of anesthetic and operative interventions and time until the initiation of surgery were recorded for both groups. Pain magnitude of the patients at the 2nd, 4th, 6th, 12th, and 24th hours following anesthetic interventions were assessed with a visual analog scale (VAS). Adverse effects such as postoperative urinary retention and postdural puncture headache were recorded. Also, patient satisfaction was recorded. Patients were interviewed by phone for anesthetic and operative complications at 72 hours postoperatively.

RESULTS

Spinal anesthesia group patients exhibited hypotension, bradycardia, postdural puncture headache, and urinary retention rates of 6.6%, 3.3%, 10%, and 3.3%, respectively. Popliteal block group patients showed none of these adverse effects. Moreover, VAS scores of the patients at the 2nd, 4th, 6th, and 12th hours were significantly lower (P < .001, P = .003, P < .001, P <.001, respectively), postoperative first analgesic requirement times were significantly longer (P < .001), and pain satisfaction scores were significantly higher (P < .001) in the popliteal block group.

CONCLUSION

Given the complications related to spinal anesthesia and its insufficiency to maintain analgesia postoperatively, we believe the preferred anesthetic method should be peripheral nerve blocks for hallux valgus correction surgeries.

LEVEL OF EVIDENCE

Level I, randomized prospective study.

Fentanyl Patches to Supplement Ultrasound-Guided Nerve Blocks for Improving Pain Control After Foot and Ankle Surgery: A Prospective Study

The analgesic effects of preoperative ultrasound-guided nerve blocks wear off after about 12 hours, leaving some patients in substantial pain. Transdermal fentanyl concentrations peak at 12 to 24 hours after application and maintain this concentration for approximately 72 hours. We sought to determine whether combining the use of a transdermal fentanyl patch with either a sciatic or femoral-sciatic nerve block would improve pain control in patients undergoing foot and/or ankle surgery. Consecutive patients in the no-patch control group (n = 104) were enrolled from July 2011 to October 2011, and those in the treatment group (n = 232) were enrolled from November 2011 to May 2012 and received a transdermal patch (4.125 mg/7.5 cm(2) releasing 25 μg of fentanyl per hour) applied to their chest postoperatively. Pain was assessed using a visual analog scale at 6, 12, 24, and 48 hours after surgery. The primary outcome measure was the number of requests for additional postoperative pain medication. Additional postoperative analgesia was requested by 49 of the 104 control patients (47.1%) and 63 of the 232 treated patients (27.1%; p = .002). The mean pain scores were also lower in the treatment group, with a statistically significant difference (p < .05) at 12, 24, and 48 hours. Thus, patients receiving a fentanyl patch combined with an ultrasound-guided nerve block required less supplemental analgesia to maintain adequate pain control than did those receiving a nerve block alone. In conclusion, a fentanyl patch is a useful adjunct to an ultrasound-guided nerve block in foot and ankle surgery.

Nerve localization techniques for peripheral nerve block and possible future directions

BACKGROUND

Ultrasound guidance is now a standard nerve localization technique for peripheral nerve block (PNB). Ultrasonography allows simultaneous visualization of the target nerve, needle, local anesthetic injectate, and surrounding anatomical structures. Accurate deposition of local anesthetic next to the nerve is essential to the success of the nerve block procedure. Due to limitations in the visibility of both needle tip and nerve surface, the precise relationship between needle tip and target nerve is unknown at the moment of injection. Importantly, nerve injury may result both from an inappropriately placed needle tip and inappropriately placed local anesthetic. The relationship between the block needle tip and target nerve is of paramount importance to the safe conduct of peripheral nerve block.

METHODS

This review summarizes the evolution of nerve localization in regional anesthesia, characterizes a problem faced by clinicians in performing ultrasound-guided nerve block, and explores the potential technological solutions to this problem.

RESULTS

To date, technology newly applied to PNB includes real-time 3D imaging, multi-planar magnetic needle guidance, and in-line injection pressure monitoring. This review postulates that optical reflectance spectroscopy and bioimpedance may allow for accurate identification of the relationship between needle tip and target nerve, currently a high priority deficit in PNB techniques.

CONCLUSIONS

Until it is known how best to define the relationship between needle and nerve at the moment of injection, some common sense principles are suggested.

Can ultrasound-guided nerve block be a useful method of anesthesia for arthroscopic knee surgery?

PURPOSE

This study was performed to compare general anesthesia, spinal anesthesia, and ultrasound (US)-guided nerve block for knee arthroscopic surgery. Also, whether US-guided nerve block is a useful method of anesthesia for arthroscopic knee surgery was investigated.

METHODS

In this prospective, randomized study, 400 patients who underwent knee arthroscopy surgery between February 2011 and September 2012 were allocated to one of three groups: spinal anesthesia (n = 100), general anesthesia (n = 100), or US-guided nerve block (n = 200). All patients completed a questionnaire with three questions 6 months after surgery. For the nerve block group, the procedure duration, interval between the procedure and onset of the anesthetic effect, the point of loss of the anesthetic effect, intraoperative, postoperative visual analog scale (VAS) pain score, and discomfort during surgery were assessed.

RESULTS

There was no patient in which the anesthetic was changed to another method during the operation. VAS pain score of postoperative 1 h was significantly different between the nerve block (1.4 ± 1.7), spinal anesthesia (1.5 ± 1.1), and general anesthesia groups (6.2 ± 5.1) (P < 0.05). In addition, VAS pain scores at postoperative 6 and 12 h were significantly different among the regional nerve block group (2.2 ± 1.5 and 3.0 ± 1.8, respectively), spinal anesthesia group (5.2 ± 3.2 and 5.1 ± 4.0, respectively), and general anesthesia group (5.2 ± 3.9 and 5.4 ± 4.5, respectively). One hundred and ninety regional nerve block (95 %), 68 spinal anesthesia (68 %), and 75 general anesthesia patients (75 %) reported that they would prefer the same type of anesthesia if they were to undergo knee surgery again; these differences were significant (P < 0.05). There were no long-term complications, such as neurological deficits or infection, after the procedure in all patients.

CONCLUSION

Arthroscopic knee surgery, such as meniscal repair or meniscectomy, synovectomy, debridement, and other procedures, was performed safely and effectively under US-guided nerve block. These results indicated that US-guided nerve block for arthroscopic knee surgery is a highly satisfactory and safe procedure without complications and is available for use by any orthopedist.

LEVEL OF EVIDENCE

Prospective case series, Level IV.

Distal peripheral neuropathy after open and arthroscopic shoulder surgery: an under-recognized complication

HYPOTHESIS

Distal peripheral neuropathy (DPN) is an under-reported complication after anatomic total shoulder arthroplasty (TSA), reverse shoulder arthroplasty (RSA), and arthroscopic rotator cuff repair (RCR).

METHODS

We conducted a retrospective review of patients undergoing shoulder arthroplasty or arthroscopic RCR by 4 shoulder surgeons during a 2-year period. The primary outcome measure was the diagnosis of DPN, defined as carpal tunnel syndrome, cubital tunnel syndrome, ulnar tunnel syndrome, and distal radial sensory neuropathy. Patient demographics and clinical course of DPN were recorded. Mean follow-up was 21, 15, and 12 months for TSA, RSA, and RCR, respectively.

RESULTS

Postoperatively, 6 of 85 TSA (7.1%), 7 of 57 RSA (12.3%), and 21 of 753 RCR (2.79%) patients were diagnosed with DPN. The most common neuropathy was cubital tunnel syndrome for TSA and RSA and carpal tunnel syndrome for RCR. The risk of DPN was higher for shoulder arthroplasty (TSA and RSA) compared with the RCR group. After nonsurgical treatment of DPN, complete resolution of symptoms occurred in 33.3% of TSA, 42.86% of RSA, and 71.43% of RCR patients. However, 16.7% of TSA, 14.3% of RSA, and 4.76% of RCR patients with DPN required surgical decompression; 100% of the patients undergoing surgical decompression had complete resolution of symptoms.

CONCLUSION

DPN is a relatively common complication after shoulder surgery. When it occurs, DPN will often resolve with nonoperative management. Surgical decompression is an effective treatment option in refractory cases.

Perioperative pain control after total knee arthroplasty: An evidence based review of the role of peripheral nerve blocks

Over the last decades, the number of total knee arthroplasty procedures performed in the United States has been increasing dramatically. This very successful intervention, however, is associated with significant postoperative pain, and adequate postoperative analgesia is mandatory in order to allow for successful rehabilitation and recovery. The use of regional anesthesia and peripheral nerve blocks has facilitated and improved this goal. Many different approaches and techniques for peripheral nerve blockades, either landmark or, more recently, ultrasound guided have been described over the last decades. This includes but is not restricted to techniques discussed in this review. The introduction of ultrasound has improved many approaches to peripheral nerves either in success rate and/or time to block. Moreover, ultrasound has enhanced the safety of peripheral nerve blocks due to immediate needle visualization and as consequence needle guidance during the block. In contrast to patient controlled analgesia using opioids, patients with a regional anesthetic technique suffer from fewer adverse events and show higher patient satisfaction; this is important as hospital rankings and advertisement have become more common worldwide and many patients use these factors in order to choose a certain institution for a specific procedure. This review provides a short overview of currently used regional anesthetic and analgesic techniques focusing on related implications, considerations and outcomes.

Ultrasound guided selective cervical nerve root block and superficial cervical plexus block for surgeries on the clavicle

We report the anaesthetic management of two cases involving surgeries on the clavicle, performed under superficial cervical plexus block and selective C5 nerve root block under ultrasound (US) guidance, along with general anaesthesia. Regional analgesia for clavicular surgeries is challenging. Our patients also had significant comorbidities necessitating individualised approach. The first patient had a history of emphysema, obesity, and was allergic to morphine and hydromorphone. The second patient had clavicular arthritis and pain due to previous surgeries. He had a history of smoking, Stevens-Johnson syndrome, along with daily marijuana and prescription opioid use. Both patients had an effective regional block and required minimal supplementation of analgesia, both being discharged on the same day. Interscalene block with its associated risks and complications may not be suitable for every patient. This report highlights the importance of selective regional blockade and also the use of US guidance for an effective and safe block.

The Cleveland Clinic experience with supraclavicular and popliteal ambulatory nerve catheters

Continuous peripheral nerve blocks (CPNB) are commonly used for intraoperative and postoperative analgesia. Our study aimed at describing our experience with ambulatory peripheral nerve catheters. After Institutional Review Board approval, records for all patients discharged with supraclavicular or popliteal catheters between January 1, 2009 and December 31, 2011 were reviewed. A licensed practitioner provided verbal and written instructions to the patients prior to discharge. Daily follow-up phone calls were conducted. Patients either removed their catheters at home with real-time simultaneous telephone guidance by a member of the Acute Pain Service or had them removed by the surgeon during a regular office visit. The primary outcome of this analysis was the incidence of complications, categorized as pharmacologic, infectious, or other. The secondary outcome measure was the average daily pain score. Our study included a total of 1059 patients with ambulatory catheters (769 supraclavicular, 290 popliteal). The median infusion duration was 5 days for both groups. Forty-two possible complications were identified: 13 infectious, 23 pharmacologic, and 6 labeled as other. Two patients had retained catheters, 2 had catheter leakage, and 2 had shortness of breath. Our study showed that prolonged use of ambulatory catheters for a median period of 5 days did not lead to an increased incidence of complications.