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Cao X, Bao M, Ma Y, Ren J, Ma W, Bao Y, Ma C, Sui X, Nie Y. Hydromorphone combined with ropivacaine for erector spinae plane block in patients undergoing modified radical mastectomy: A prospective randomized controlled trial. Medicine (Baltimore) 2024; 103:e38758. [PMID: 38941366 DOI: 10.1097/md.0000000000038758] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 06/30/2024] Open
Abstract
BACKGROUND Combining hydromorphone with ropivacaine in ultrasound-guided erector spinae plane blocks enhances postoperative analgesia and reduces interleukin-6 expression in breast surgery patients. METHODS In this study, breast cancer patients undergoing modified radical mastectomy were randomized into 3 groups for anesthesia (30 patients in each group): standard general (group C), Erector Spinae Plane Block (ESPB) with ropivacaine (group R), and ESPB with ropivacaine plus hydromorphone (group HR). Diagnosis: Breast cancer patients. Postsurgery, pain levels, IL-6, anesthetic doses, additional analgesia needs, and recovery milestones were compared to evaluate the efficacy of the ESPB enhancements. RESULTS The 3 groups were not significantly different in baseline characteristics, operation time, number of cases with postoperative nausea, and serum IL-6 concentrations at T1 (the time of being returned to the ward after surgery). At T2 (at 6:00 in the next morning after surgery), the serum IL-6 concentration in group HR was significantly lower than that in groups R and C (P < .05); the intraoperative doses of remifentanil, sufentanil, and propofol were significantly lower in groups HR and R than those in group C (P < .05); Groups HR and R had significantly lower visual analog scale scores at T3 (4 hours postoperatively), T4 (12 hours postoperatively), and T5 (24 hours postoperatively) than those in group C (P < .05); the proportions of patients receiving postoperative remedial analgesia were significantly lower in groups HR and R than in group C (P < .05); groups HR and R had significantly lower proportions of patients with postoperative nausea than group C (P < .05); the time to the first anal exhaust and the time to the first ambulation after surgery were significantly shorter in groups HR and R than those in group C (P < .05). CONCLUSION Hydromorphone combined with ropivacaine for ESPB achieved a greater postoperative analgesic effect for patients receiving MRM under general anesthesia. The combined analgesia caused fewer adverse reactions and inhibited the expression level of the inflammatory factor IL-6 more effectively, thereby facilitating postoperative recovery. ESPB using hydromorphone with ropivacaine improved pain control post-MRM, reduced adverse effects, and more effectively suppressed IL-6, enhancing recovery.
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Affiliation(s)
- Xue Cao
- Graduate School of Inner Mongolia Medical University, Hohhot, China
- Department of Anesthesiology, Xing'anmeng People's Hospital, Ulanhot, China
| | - Malian Bao
- Department of Anesthesiology, Inner Mongolia Forth Hospital, Hohhot, China
| | - Yuhua Ma
- Department of Anesthesiology, Xing'anmeng People's Hospital, Ulanhot, China
| | - Jie Ren
- Department of Anesthesiology, Xing'anmeng People's Hospital, Ulanhot, China
| | - Weiwei Ma
- Department of Anesthesiology, Xing'anmeng People's Hospital, Ulanhot, China
| | - Yongli Bao
- Department of Anesthesiology, Xing'anmeng People's Hospital, Ulanhot, China
| | - Changfei Ma
- Department of Anesthesiology, Xing'anmeng People's Hospital, Ulanhot, China
| | - Xin Sui
- Department of Anesthesiology, Xing'anmeng People's Hospital, Ulanhot, China
| | - Yongzhen Nie
- Department of Anesthesiology, Peking University Cancer Hospital Inner Mongolia Hospital, Hohhot, China
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Jo Y, Oh C, Lee WY, Chung HJ, Park H, Park J, Lee J, Kim YH, Ko Y, Chung W, Hong B. Effect of local anesthetic volume (20 vs. 40 ml) on the analgesic efficacy of costoclavicular block in arthroscopic shoulder surgery: a randomized controlled trial. Korean J Anesthesiol 2024; 77:85-94. [PMID: 37679899 PMCID: PMC10834710 DOI: 10.4097/kja.23260] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/05/2023] [Revised: 08/18/2023] [Accepted: 08/18/2023] [Indexed: 09/09/2023] Open
Abstract
BACKGROUND Among the various diaphragm-sparing alternatives to interscalene block, costoclavicular block (CCB) demonstrated a low hemidiaphragmatic paresis (HDP) occurrence but an inconsistent analgesic effect in arthroscopic shoulder surgery. We hypothesized that a larger volume of local anesthetic for CCB could provide sufficient analgesia by achieving sufficient supraclavicular spreading. METHODS Sixty patients scheduled for arthroscopic rotator cuff repair were randomly assigned to receive CCB using one of two volumes of local anesthetic (CCB20, 0.75% ropivacaine 20 ml; CCB40, 0.375% ropivacaine 40 ml). The primary outcome was the rate of complete analgesia (0 on the numeric rating scale of pain) at 1 h postoperatively. The secondary outcomes included a sonographic assessment of local anesthetic spread, diaphragmatic function, pulmonary function, postoperative opioid use, and other pain-related experiences within 24 h postoperatively. RESULTS The rates of complete analgesia were not significantly different (23.3% [7/30] and 33.3% [10/30] in the CCB20 and CCB40 groups, respectively; risk difference 10%, 95% CI [-13, 32], P = 0.567). There were no significant differences in other pain-related outcomes. Among the clinical factors considered, the only factor significantly associated with postoperative pain was the sonographic observation of supraclavicular spreading. There were no significant differences in the incidence of HDP and the change in pulmonary function between the two groups. CONCLUSIONS Using 40 ml of local anesthetic does not guarantee supraclavicular spread during CCB. Moreover, it does not result in a higher rate of complete analgesia compared to using 20 ml of local anesthetic in arthroscopic shoulder surgery.
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Affiliation(s)
- Yumin Jo
- Department of Anesthesiology and Pain Medicine, Chungnam National University Hospital, Chungnam National University College of Medicine, Daejeon, Korea
| | - Chahyun Oh
- Department of Anesthesiology and Pain Medicine, Chungnam National University Hospital, Chungnam National University College of Medicine, Daejeon, Korea
| | - Woo-Yong Lee
- Department of Orthopedic Surgery, Chungnam National University Hospital, Chungnam National University College of Medicine, Daejeon, Korea
| | - Hyung-Jin Chung
- Department of Orthopedic Surgery, Chungnam National University Hospital, Chungnam National University College of Medicine, Daejeon, Korea
| | - Hanmi Park
- Department of Anesthesiology and Pain Medicine, Chungnam National University Hospital, Chungnam National University College of Medicine, Daejeon, Korea
| | - Juyeon Park
- Department of Anesthesiology and Pain Medicine, Chungnam National University Hospital, Chungnam National University College of Medicine, Daejeon, Korea
| | - Jieun Lee
- Department of Anesthesiology and Pain Medicine, Chungnam National University Hospital, Chungnam National University College of Medicine, Daejeon, Korea
| | - Yoon-Hee Kim
- Department of Anesthesiology and Pain Medicine, Chungnam National University Hospital, Chungnam National University College of Medicine, Daejeon, Korea
| | - Youngkwon Ko
- Department of Anesthesiology and Pain Medicine, Chungnam National University Hospital, Chungnam National University College of Medicine, Daejeon, Korea
- Biomedical Research Institute, Chungnam National University Hospital, Daejeon, Korea
| | - Woosuk Chung
- Department of Anesthesiology and Pain Medicine, Chungnam National University Hospital, Chungnam National University College of Medicine, Daejeon, Korea
| | - Boohwi Hong
- Department of Anesthesiology and Pain Medicine, Chungnam National University Hospital, Chungnam National University College of Medicine, Daejeon, Korea
- Biomedical Research Institute, Chungnam National University Hospital, Daejeon, Korea
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Zerbinati P, Bemporad J, Massimiani A, Bianchini E, Mazzoli D, Glorioso D, della Vecchia G, De Luca A, De Blasiis P. Lateral Pectoral Nerve Identification through Ultrasound-Guided Methylene Blue Injection during Selective Peripheral Neurectomy for Shoulder Spasticity: Proposal for a New Procedure. J Pers Med 2024; 14:116. [PMID: 38276238 PMCID: PMC10817262 DOI: 10.3390/jpm14010116] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/09/2023] [Revised: 01/12/2024] [Accepted: 01/17/2024] [Indexed: 01/27/2024] Open
Abstract
Internally rotated and adducted shoulder is a common posture in upper limb spasticity. Selective peripheral neurectomy is a useful and viable surgical technique to ameliorate spasticity, and the lateral pectoral nerve (LPN) could be a potential good target to manage shoulder spasticity presenting with internal rotation. However, there are some limitations related to this procedure, such as potential anatomical variability and the necessity of intraoperative surgical exploration to identify the target nerve requiring wide surgical incisions. This could result in higher post-surgical discomfort for the patient. Therefore, the aim of our study was to describe a modification of the traditional selective peripheral neurectomy procedure of the LPN through the perioperative ultrasound-guided marking of the target nerve with methylene blue. The details of the localization and marking procedure are described, as well as the surgical technique of peripheral selective neurectomy and the potential advantages in terms of nerve localization, surgical precision and patients' post-surgical discomfort. We suggest that the proposed modified procedure could be a valid technique to address some current limitations and move the surgical treatment of spasticity toward increasingly tailored management due to the ease of nerve identification, the possibility of handling potential anatomical variability and the resulting smaller surgical incisions.
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Affiliation(s)
- Paolo Zerbinati
- Neuro-Orthopedic Unit, Sol et Salus Hospital, 47922 Rimini, Italy (J.B.); (D.G.)
| | - Jonathan Bemporad
- Neuro-Orthopedic Unit, Sol et Salus Hospital, 47922 Rimini, Italy (J.B.); (D.G.)
| | - Andrea Massimiani
- Department of Neuroscience, Mental Health and Sensory Organs (NESMOS), Sapienza University of Rome, 00189 Rome, Italy; (A.M.); (E.B.)
| | - Edoardo Bianchini
- Department of Neuroscience, Mental Health and Sensory Organs (NESMOS), Sapienza University of Rome, 00189 Rome, Italy; (A.M.); (E.B.)
| | - Davide Mazzoli
- Gait and Motion Analysis Laboratory, Sol et Salus Hospital, 47992 Rimini, Italy;
| | - Davide Glorioso
- Neuro-Orthopedic Unit, Sol et Salus Hospital, 47922 Rimini, Italy (J.B.); (D.G.)
| | - Giuseppe della Vecchia
- Department of Women, Child, General and Specialistic Surgery, University of Campania “L. Vanvitelli”, 80138 Naples, Italy;
| | - Antonio De Luca
- Section of Human Anatomy, Department of Mental and Physical Health and Preventive Medicine, University of Campania “Luigi Vanvitelli”, Via Luciano Armanni, 5, 80138 Naples, Italy;
| | - Paolo De Blasiis
- Section of Human Anatomy, Department of Mental and Physical Health and Preventive Medicine, University of Campania “Luigi Vanvitelli”, Via Luciano Armanni, 5, 80138 Naples, Italy;
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Herzog S, David R, Speirs A, Hashemi M, Winston P. A Case Report Illustrating the Combined Use of Cryoneurolysis and Percutaneous Needle Tenotomy in the Treatment of Longstanding Spastic Shoulder Contractures After Stroke. Arch Rehabil Res Clin Transl 2023; 5:100285. [PMID: 37744199 PMCID: PMC10517357 DOI: 10.1016/j.arrct.2023.100285] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 09/26/2023] Open
Abstract
Adduction and internal rotation of the shoulder is a common presentation in post-stroke patients, and can often be caused by spasticity and musculotendinous retraction causing a contracture of the pectoralis major and minor muscles. A post cerebral arteriovenous malfunction rupture patient with severe refractory left shoulder spasticity with contracture was treated with cryoneurolysis to the medial and lateral pectoral nerves, combined with a percutaneous needle tenotomy to the pectoralis major tendon. There was an improvement in shoulder forward flexion, abduction and external rotation immediately and found sustained at 8 weeks by 50°, 45°, and 15°. The patient noted an immediate cessation of limitation of shoulder abduction, a liberation of range of motion of the shoulder, and looseness in their arm and shoulder. They reported a dramatic improvement in their gait, increased independence, and an improvement in overall quality of life in a structured interview 8 weeks after the procedure. The patient relayed a positive experience with the combined neuro-orthopedic procedure of cryoneurolysis and tenotomy for the treatment of their spastic shoulder. This combined treatment could be considered as a management strategy for patients experiencing shoulder spasticity with contracture.
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Affiliation(s)
- Samuel Herzog
- Faculty of Science University of British Columbia, Vancouver BC, Canada
| | - Romain David
- Vancouver Island Health Authority, Victoria, BC, Canada
- Physical and Rehabilitation Medicine Unit, Poitiers University Hospital, University of Poitiers, 86021 Poitiers, France
- PRISMATICS Lab (Predictive Research in Spine/Neuromodulation Management and Thoracic Innovation/Cardiac Surgery), Poitiers University Hospital, Poitiers, France
| | - Abby Speirs
- Vancouver Island Health Authority, Victoria, BC, Canada
| | | | - Paul Winston
- Vancouver Island Health Authority, Victoria, BC, Canada
- Division of Physical Medicine and Rehabilitation, University of British Columbia, Faculty of Medicine, Victoria, BC, Canada
- Canadian Advances in Neuro-Orthopedics for Spasticity Consortium, Kingston, ON, Canada
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Shiraishi M, Sowa Y, Tsuge I, Shiraishi A, Inafuku N, Morimoto N, Nakayama I. Characteristics and distribution of chronic pain after mastectomy and breast reconstruction: a long-term prospective cohort study. Surg Today 2023:10.1007/s00595-023-02676-y. [PMID: 37000256 DOI: 10.1007/s00595-023-02676-y] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/20/2022] [Accepted: 12/21/2022] [Indexed: 04/01/2023]
Abstract
PURPOSE Chronic pain following breast surgery is a concern for breast cancer survivors; however, few studies have investigated the localization of persistent postoperative pain. We conducted this study to identify the location of pain following breast reconstruction. METHODS A total of 213 Japanese women undergoing mastectomy only or breast reconstruction with a tissue expander/implant (TE/Imp) or a deep inferior epigastric perforator (DIEP) flap were enrolled in the study. Questionnaires related to pain location were sent to patients at the end of postoperative year (POY) 1 and POY 5. Multiple comparisons of the types of operation and cross-tabulation were made between the two time points. RESULTS Surveys were completed by 107 of the women. Severe pain in the upper medial breast was significantly more common in POY 1 after DIEP reconstruction than after mastectomy only (P = 0.01), whereas abdominal pain was worse in POY 5 after DIEP reconstruction than after mastectomy only (P = 0.04). Pain in the medial arm and axilla had resolved better after TE/Imp (P = 0.03) and DIEP reconstruction (P = 0.01) than after mastectomy only by POY 5, but the difference between TE/Imp and DIEP reconstruction was not significant. CONCLUSIONS These results show that localization of prolonged postoperative pain following breast reconstruction differs depending on the surgical strategy.
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Affiliation(s)
- Makoto Shiraishi
- Department of Plastic and Reconstructive Surgery, Graduate School of Medical Science, Kyoto Prefectural University of Medicine, Kyoto, Japan
- Department of Plastic and Reconstructive Surgery, Graduate School of Medicine, Mie University, Tsu, Japan
| | - Yoshihiro Sowa
- Department of Plastic and Reconstructive Surgery, Graduate School of Medical Science, Kyoto Prefectural University of Medicine, Kyoto, Japan.
- Department of Plastic and Reconstructive Surgery, Graduate School of Medicine and Faculty of Medicine, Kyoto University, 54 Shogoin Kawahara-cho, Sakyou-ku, Kyoto, 606-8507, Japan.
| | - Itaru Tsuge
- Department of Plastic and Reconstructive Surgery, Graduate School of Medicine and Faculty of Medicine, Kyoto University, 54 Shogoin Kawahara-cho, Sakyou-ku, Kyoto, 606-8507, Japan
| | - Akiko Shiraishi
- Department of Plastic and Reconstructive Surgery, Graduate School of Medical Science, Kyoto Prefectural University of Medicine, Kyoto, Japan
| | - Naoki Inafuku
- Department of Plastic and Reconstructive Surgery, Graduate School of Medical Science, Kyoto Prefectural University of Medicine, Kyoto, Japan
| | - Naoki Morimoto
- Department of Plastic and Reconstructive Surgery, Graduate School of Medicine and Faculty of Medicine, Kyoto University, 54 Shogoin Kawahara-cho, Sakyou-ku, Kyoto, 606-8507, Japan
| | - Ichiro Nakayama
- Department of Breast Surgery, Kyoto Miniren Chuo Hospital, Kyoto, Japan
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Patel NT, Smith HF. Clinically Relevant Anatomical Variations in the Brachial Plexus. Diagnostics (Basel) 2023; 13:diagnostics13050830. [PMID: 36899974 PMCID: PMC10001373 DOI: 10.3390/diagnostics13050830] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/05/2023] [Revised: 02/16/2023] [Accepted: 02/19/2023] [Indexed: 02/24/2023] Open
Abstract
Anatomical variation in the brachial plexus may result in a variety of clinically relevant patterns, including various neuralgias of the upper extremity and differing nerve territories. Some conditions can be debilitating in symptomatic patients, resulting in paresthesia, anesthesia, or weakness of the upper extremity. Others may simply result in cutaneous nerve territories that deviate from a traditional dermatome map. This study evaluated the frequency and anatomical presentations of a large number of clinically relevant brachial plexus nerve variations in a sample of human body donors. We identified a high frequency of various branching variants, of which clinicians, especially surgeons, should be aware. The medial pectoral nerves in 30% of the sample were found to originate from either the lateral cord, or both the medial and lateral cords of the brachial plexus rather than exclusively from the medial cord. The dual cord innervation pattern greatly increases the number of spinal cord levels traditionally believed to innervate the pectoralis minor muscle. The thoracodorsal nerve arose as a branch of the axillary nerve 17% of the time. The musculocutaneous nerve sent branches to the median nerve in 5% of specimens. The medial antebrachial cutaneous nerve shared a common trunk with the medial brachial cutaneous nerve in 5% of individuals and derived from the ulnar nerve in 3% of specimens.
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Affiliation(s)
- Niki T. Patel
- Arizona College of Osteopathic Medicine, Midwestern University, Glendale, AZ 85308, USA
| | - Heather F. Smith
- Arizona College of Osteopathic Medicine, Midwestern University, Glendale, AZ 85308, USA
- Department of Anatomy, College of Graduate Studies, Midwestern University, Glendale, AZ 85308, USA
- School of Human Evolution and Social Change, Arizona State University, Tempe, AZ 85287, USA
- Correspondence: ; Tel.: +1-623-572-3726
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Jo Y, Oh C, Lee WY, Chung HJ, Park J, Kim YH, Ko Y, Chung W, Hong B. Randomised comparison between superior trunk and costoclavicular blocks for arthroscopic shoulder surgery: A noninferiority study. Eur J Anaesthesiol 2022; 39:810-817. [PMID: 35975762 DOI: 10.1097/eja.0000000000001735] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
BACKGROUND Superior trunk block (STB) provides noninferior analgesia to the interscalene block and reduces the risk of hemidiaphragmatic paralysis (HDP). Recently, supraclavicular spreading has also been shown to occur during costoclavicular block (CCB), presenting as an alternative analgesic technique for shoulder surgery. OBJECTIVE The aim of this study was to determine whether there is a difference in postoperative pain scores and HDP incidence between STB and CCB. DESIGN Prospective randomised controlled trial. SETTING Chungnam National University Hospital in Daejeon from January to July 2021. PATIENTS Seventy patients, aged 20 to 70 years with ASA Physical Status classifications I to III and scheduled for elective arthroscopic rotator cuff repair were recruited. INTERVENTION Ultrasound-guided STB or CCB was performed with 20 ml 0.5% ropivacaine. MAIN OUTCOME MEASURES The primary outcome was the pain score (numeric rating scale, NRS) at 1 h postsurgery. A 1.4 (NRS) noninferiority margin was set a priori . The incidence of HDP, postoperative change of pulmonary function and postoperative opioid use were included as secondary outcomes. RESULTS The pain score was higher in the CCB group compared with the STB group at 1 h postoperatively (median difference, 2; 95% confidence interval (CI), 1 to 3; noninferiority was not demonstrated). Two patients in the CCB group received a rescue interscalene block due to severe postoperative pain. The incidence of complete HDP was lower in the CCB group (risk difference, -26%; 95% CI, -6 to -45%; P < 0.001). The median reduction in forced vital capacity and forced expiratory volume in 1 s were also significantly lower in the CCB group. CONCLUSION Although the incidence of HDP was lower, CCB did not show noninferiority in immediate postoperative analgesia compared with STB in arthroscopic shoulder surgery. CLINICAL TRIAL REGISTRATION Clinical Trial Registry of Korea (KCT0005822, principal investigator: Boohwi Hong) on 25 January 2021 ( https://cris.nih.go.kr ).
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Affiliation(s)
- Yumin Jo
- From the Department of Anaesthesiology and Pain Medicine (YJ, CO, JP, Y-HK, YK, WC, BH), Department of Orthopaedic surgery, Chungnam National University Hospital, College of Medicine (W-YL, H-JC) and Biomedical Research Institute, Chungnam National University Hospital, Daejeon, Korea (YK, BH)
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Benes M, Kachlik D, Belbl M, Havlikova S, Kunc V, Whitley A, Kaiser R, Kunc V. A meta-analysis on the anatomical variability of the brachial plexus: Part III - Branching of the infraclavicular part. Ann Anat 2022; 244:151976. [PMID: 35787441 DOI: 10.1016/j.aanat.2022.151976] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/14/2022] [Revised: 05/21/2022] [Accepted: 06/12/2022] [Indexed: 11/17/2022]
Abstract
INTRODUCTION The anatomy of the brachial plexus has been a subject of interest to many researchers over time resulting in an inconsistent amount of data. Previously, our team had published two evidence-based studies on the anatomical variations involving the brachial plexus, therefore the aim of this study was to analyze the findings regarding the infraclavicular part of the brachial plexus with the use of meta-analytic techniques to complete the comprehensive series. MATERIAL AND METHODS Major scientific databases were extensively searched to compile anatomical studies investigating the morphology of the infraclavicular part of the brachial plexus. Extracted data were classified based on our proposed classification system and subsequently analyzed with the use of random effects meta-analysis to state the pooled prevalence estimates of the distinct variation patterns. RESULTS A total of 75 studies (4772 upper limbs) were selected for the meta-analysis. The branches of the lateral cord, including the lateral pectoral nerve and musculocutaneous nerve, resembled their usual origin in 76.8% (95% CI 50-96%) and 98.8% (95% CI 98-100%), respectively. The medial pectoral nerve, medial brachial cutaneous nerves, medial antebrachial cutaneous nerve and ulnar nerve emerging from the medial cord were observed originating from their usual origins in 90.9% (95% CI 68-100%), 90.7% (95% CI 73-100%), 87.9% (95% CI 67-99%) and 97.7% (95% CI 94-100%), respectively. Lastly, nerves branching from the posterior cord, including the superior and inferior subscapular nerves, thoracodorsal nerve, axillary nerve and radial nerve, originated as per textbook description in 90.7% (95% CI 80-98%), 76.1% (95% CI 61-89%), 90.1% (95% CI 84-95%), 79.8% (95% CI 68-90%) and 99.0% (95% CI 96-100%), respectively. Moreover, the usual origin of the median nerve from the lateral and medial cord via the corresponding roots was encountered in 89.7% (95% CI 84-95%) of cases. CONCLUSIONS The nerves originating from the infraclavicular part of the brachial plexus exhibit a wide spectrum of possible origins. However, the usual patterns were significantly the most common types present in more than three quarters of cases. Especially clinicians might profit from the enhanced understanding of the brachial plexus anatomy presented herein, since we offer a strong guide for handling the anatomically challenging pathologies in this specific area.
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Affiliation(s)
- Michal Benes
- Department of Anatomy, Second Faculty of Medicine, Charles University, Plzenska 130/221, 150 06 Prague 5, Czech Republic
| | - David Kachlik
- Department of Anatomy, Second Faculty of Medicine, Charles University, Plzenska 130/221, 150 06 Prague 5, Czech Republic; Department of Health Care Studies, College of Polytechnics, Tolsteho 16, 586 01 Jihlava, Czech Republic
| | - Miroslav Belbl
- Department of Anatomy, Second Faculty of Medicine, Charles University, Plzenska 130/221, 150 06 Prague 5, Czech Republic
| | - Sarlota Havlikova
- Department of Anatomy, Second Faculty of Medicine, Charles University, Plzenska 130/221, 150 06 Prague 5, Czech Republic
| | - Vladimir Kunc
- Department of Computer Science, Czech Technical University, Karlovo namesti 13, 121 35 Prague 2, Czech Republic
| | - Adam Whitley
- Department of Anatomy, Second Faculty of Medicine, Charles University, Plzenska 130/221, 150 06 Prague 5, Czech Republic; Department of Surgery, University Hospital Kralovske Vinohrady, Third Faculty of Medicine, Charles University, Srobarova 50, 100 34 Prague 10, Czech Republic
| | - Radek Kaiser
- Department of Neurosurgery and Neurooncology, Military University Hospital, First Faculty of Medicine, Charles University, U vojenske nemocnice 1200, 169 02 Prague 6, Czech Republic
| | - Vojtech Kunc
- Department of Anatomy, Second Faculty of Medicine, Charles University, Plzenska 130/221, 150 06 Prague 5, Czech Republic; Clinic of Trauma Surgery, Masaryk Hospital, Socialni pece 3316/12A, 400 11 Usti nad Labem, Czech Republic.
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Sertcakacilar G, Kose S. Bilateral PECS II block is associated with decreased opioid consumption and reduced pain scores for up to 24 hours after minimally invasive repair of pectus excavatum (Nuss procedure): a retrospective analysis. J Cardiothorac Vasc Anesth 2022; 36:3833-3840. [DOI: 10.1053/j.jvca.2022.06.001] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/27/2022] [Revised: 05/21/2022] [Accepted: 06/01/2022] [Indexed: 11/11/2022]
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Shiraishi M, Sowa Y, Kodama T, Numajiri T, Taguchi T, Amaya F. Localization of Chronic Pain in Postmastectomy Patients: A Prospective Comparison Between Patients With and Without Breast Reconstruction. Ann Plast Surg 2022; 88:490-495. [PMID: 35443265 DOI: 10.1097/sap.0000000000003146] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/31/2022]
Abstract
BACKGROUND After breast surgery with or without immediate reconstruction, chronic pain can be a major problem for patients. However, few studies have examined the details of the sites of long-lasting postoperative pain. In this study, we specified the postoperative pain location after breast surgery, including reconstruction, to find ways to improve surgical procedures or provide effective pain relief. METHODS The subjects were 205 Japanese women undergoing mastectomy or breast reconstruction with a tissue expander (TE)/implant or a deep inferior epigastric perforator (DIEP) flap. Patients were asked whether they had pain in different parts of the body at 1 year after surgery. Differences were assessed by cross-tabulation and χ2 statistics. RESULTS Surveys were completed by 157 subjects. Deep inferior epigastric perforator flap cases had significantly more pain and TE/Imp cases had significantly less pain in the medial breast, upper breast, breast upper medial quadrant, and abdomen (P = 0.006, P = 0.006, P < 0.001, P < 0.001, respectively). In the neck area, pain in TE/Imp cases was significantly worse than that in all other patients (P = 0.025). There was no significant difference in chronic pain in any other body regions among the mastectomy only, TE/Imp, and DIEP flap groups. CONCLUSIONS The results of the present study revealed that the localization of prolonged postoperative pain after breast surgery differs depending on the surgical procedure. In DIEP flap reconstruction, there was a marked tendency for pain in the inner and upper chest and in the abdomen, whereas TE/IMP surgery resulted in pain around the neck of the affected side. These findings may help improve surgical methods and establish effective pain relief that focuses on the identified pain areas.
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Affiliation(s)
| | - Yoshihiro Sowa
- From the Department of Plastic and Reconstructive Surgery, Graduate School of Medical Science, Kyoto Prefectural University of Medicine
| | - Takuya Kodama
- From the Department of Plastic and Reconstructive Surgery, Graduate School of Medical Science, Kyoto Prefectural University of Medicine
| | - Toshiaki Numajiri
- From the Department of Plastic and Reconstructive Surgery, Graduate School of Medical Science, Kyoto Prefectural University of Medicine
| | | | - Fumimasa Amaya
- Pain Management and Palliative Care Medicine, Graduate School of Medical Science, Kyoto Prefectural University of Medicine, Kyoto, Japan
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Lin J, Liao Y, Gong C, Yu L, Gao F, Yu J, Chen J, Chen X, Zheng T, Zheng X. Regional Analgesia in Video-Assisted Thoracic Surgery: A Bayesian Network Meta-Analysis. Front Med (Lausanne) 2022; 9:842332. [PMID: 35463038 PMCID: PMC9019113 DOI: 10.3389/fmed.2022.842332] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/23/2021] [Accepted: 02/28/2022] [Indexed: 12/20/2022] Open
Abstract
Background A variety of regional analgesia methods are used during video-assisted thoracic surgery (VATS). Our network meta-analysis (NMA) sought to evaluate the advantages of various methods of localized postoperative pain management in VATS patients. Methods PubMed, the Cochrane Library, and EMBASE were searched from their date of inception to May 2021 for randomized controlled trials (RCTs) comparing two or more types of locoregional analgesia in adults using any standardized clinical criteria. This was done using Bayesian NMA. Results A total of 3,563 studies were initially identified, and 16 RCTs with a total of 1,144 participants were ultimately included. These studies, which spanned the years 2014 to 2021 and included data from eight different countries, presented new information. There were a variety of regional analgesia techniques used, and in terms of analgesic effect, thoracic epidural anesthesia (TEA) [SMD (standard mean difference) = 1.12, CrI (Credible interval): (-0.08 to -2.33)], thoracic paravertebral block (TPVB) (SMD = 0.67, CrI: (-0.25 to 1.60) and erector spinae plane block (ESPB) (SMD = 0.34, CrI: (-0.5 to 1.17) were better than other regional analgesia methods. Conclusion Overall, these findings show that TEA, TPVB and ESPB may be effective forms of regional analgesia in VATS. This research could be a valuable resource for future efforts regarding the use of thoracic regional analgesia and enhanced recovery after surgery. Systematic Review Registration Identifier [PROSPERO CRD42021253218].
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Affiliation(s)
- Jingfang Lin
- Department of Anesthesiology, Fujian Provincial Hospital, Shengli Clinical Medical College of Fujian Medical University, Fuzhou, China
| | - Yanling Liao
- Department of Anesthesiology, Fujian Provincial Hospital, Shengli Clinical Medical College of Fujian Medical University, Fuzhou, China
| | - Cansheng Gong
- Department of Anesthesiology, Fujian Provincial Hospital, Shengli Clinical Medical College of Fujian Medical University, Fuzhou, China
| | - Lizhu Yu
- Department of Anesthesiology, Fujian Provincial Hospital, Shengli Clinical Medical College of Fujian Medical University, Fuzhou, China
| | - Fei Gao
- Department of Anesthesiology, Fujian Provincial Hospital, Shengli Clinical Medical College of Fujian Medical University, Fuzhou, China
| | - Jing Yu
- Department of Anesthesiology, Fujian Provincial Hospital, Shengli Clinical Medical College of Fujian Medical University, Fuzhou, China
| | - Jianghu Chen
- Department of Anesthesiology, Fujian Provincial Hospital, Shengli Clinical Medical College of Fujian Medical University, Fuzhou, China
| | - Xiaohui Chen
- Department of Anesthesiology, Fujian Provincial Hospital, Shengli Clinical Medical College of Fujian Medical University, Fuzhou, China
| | - Ting Zheng
- Department of Anesthesiology, Fujian Provincial Hospital, Shengli Clinical Medical College of Fujian Medical University, Fuzhou, China
| | - Xiaochun Zheng
- Department of Anesthesiology, Fujian Provincial Hospital, Shengli Clinical Medical College of Fujian Medical University, Fuzhou, China
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12
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Pectoralis Major Rupture: Evaluation and Management. J Am Acad Orthop Surg 2022; 30:e617-e627. [PMID: 35025841 DOI: 10.5435/jaaos-d-21-00541] [Citation(s) in RCA: 5] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/25/2021] [Accepted: 12/10/2021] [Indexed: 02/01/2023] Open
Abstract
Pectoralis major tendon ruptures are being reported with increasing frequency and primarily occur in young, high demand, male patients. The injury results from an eccentric contracture of the muscle most commonly while performing the bench press maneuver during weight training. In the setting of both acute and chronic injury, physical examination is critical for a timely and accurate diagnosis. During physical examination, comparison with the opposite side is imperative, and findings may include swelling, ecchymosis, loss of the anterior axillary fold, and a decreased pectoralis major index. Surgical treatment of acute ruptures is superior to nonsurgical treatment and results in improved functional outcomes and high levels of return to work and sport. Repair of chronic tears is more challenging and may require reconstruction with autograft or allograft tissue. Despite advances in surgical technique, tendon rerupture, persistent pain, and wound infection remain a concern.
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13
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Pretterklieber B, Metka S, Klöppel M, Pretterklieber ML. Extramuscular and Intramuscular Course of the Nerve Innervating the Abdominal Part of the Pectoralis Major Muscle: An Anatomical Study with Regard to Transaxillary Endoscopic Subpectoral Breast Augmentation. Plast Reconstr Surg 2022; 149:410e-416e. [PMID: 35196672 DOI: 10.1097/prs.0000000000008814] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
BACKGROUND During transaxillary endoscopic subpectoral breast augmentation, the innervation of the abdominal part of the pectoralis major muscle can be injured. The question has been raised whether this could even be of value, as for a better result, the caudal fibers of the pectoralis major muscle have to be detached from their origin. The authors' aim was to identify the exact position and the intramuscular course and target of these nerve branches. METHODS Fifty pectoralis major muscles and their supplying nerve branches from 27 formalin-fixed anatomical specimens were studied using macroscopic dissection and anthropometry. Furthermore, eight muscles underwent the modified Sihler procedure to determine the intramuscular course and target of the supplying nerve branches. RESULTS The branches for the abdominal part of the pectoralis major muscle pierced the pectoralis minor muscle or coursed around its lower border 3.2 to 8.4 cm from the tip of the coracoid process. Within the muscle, at least one small nerve branch, innervating the abdominal part, ascended into the lowermost portion of the sternocostal head, and anastomosed with the lowest small branch of its supplying nerve branches. CONCLUSIONS Because of the variable position of the nerve branches, they may often cross the operative field during transaxillary endoscopic breast augmentation. However, their interruption can be of value, because weakening of the lower part of the pectoralis major muscle is desired to keep the implant in place, and to avoid animation deformity.
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Affiliation(s)
- Bettina Pretterklieber
- From Macroscopic and Clinical Anatomy, Gottfried Schatz Research Center, Medical University of Graz; the Division of Anatomy, Center for Anatomy and Cell Biology, Medical University of Vienna; and Dr. Klöppel & Kollegen, Ästhetische Chirurgie & Medizin, MediCenter München Solln
| | - Susanne Metka
- From Macroscopic and Clinical Anatomy, Gottfried Schatz Research Center, Medical University of Graz; the Division of Anatomy, Center for Anatomy and Cell Biology, Medical University of Vienna; and Dr. Klöppel & Kollegen, Ästhetische Chirurgie & Medizin, MediCenter München Solln
| | - Markus Klöppel
- From Macroscopic and Clinical Anatomy, Gottfried Schatz Research Center, Medical University of Graz; the Division of Anatomy, Center for Anatomy and Cell Biology, Medical University of Vienna; and Dr. Klöppel & Kollegen, Ästhetische Chirurgie & Medizin, MediCenter München Solln
| | - Michael L Pretterklieber
- From Macroscopic and Clinical Anatomy, Gottfried Schatz Research Center, Medical University of Graz; the Division of Anatomy, Center for Anatomy and Cell Biology, Medical University of Vienna; and Dr. Klöppel & Kollegen, Ästhetische Chirurgie & Medizin, MediCenter München Solln
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14
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Madhavan CM, Rajasekharan S, Varghese S. Anatomy of lateral pectoral nerve and its clinical significance. NATIONAL JOURNAL OF CLINICAL ANATOMY 2022. [DOI: 10.4103/njca.njca_23_22] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/04/2022] Open
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15
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Should the 'normal' and 'ideal' nipple position in a male influence the surgeon when planning severe gynaecomastia correction? J Plast Reconstr Aesthet Surg 2021; 75:1438-1446. [PMID: 34952808 DOI: 10.1016/j.bjps.2021.11.041] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/22/2020] [Revised: 11/07/2021] [Accepted: 11/09/2021] [Indexed: 11/23/2022]
Abstract
BACKGROUND The ideal nipple areolar complex (NAC) position of the male chest following gynaecomastia surgery is well documented; however, with increased development of the chest muscles, the NAC placement can change, leading to the medial displacement of the nipple giving a poor aesthetic outcome. Therefore, we believe that these measurements need to be applied to the patients' build and take into consideration the future fitness goals of the patients. METHOD We have analysed the photographs of three groups of men: super athletes, athletes and individuals with severe gynaecomastia. We have assessed the proportions of the chest in relation to the NAC, degree of ptosis and TAP index. RESULTS There was a wide variation between the athlete and the super athlete group, with minor variations within each group. The range of measurement in the severe gynaecomastia group was significantly larger than those in the other groups. We feel that based on this research study, surgeons should however be somewhat circumspect in their choice of nipple position as there is a wide variation in what can be considered as normal, and positioning of the NAC too early in the recovery process may lead to an abnormal aesthetic appearance following muscle development. CONCLUSION Despite the multitude of techniques available in the literature to determine the position of nipple, there is a lack of understanding on how the NAC position changes with muscle development. Adopting a dogmatic approach may result in a very aesthetically displeasing outcome, which can be very difficult to correct in men.
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16
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Jo Y, Park S, Oh C, Pak Y, Jeong K, Yun S, Noh C, Chung W, Kim YH, Ko YK, Hong B. Regional analgesia techniques for video assisted thoracic surgery: a frequentist network meta-analysis. Korean J Anesthesiol 2021; 75:231-244. [PMID: 34638182 PMCID: PMC9171539 DOI: 10.4097/kja.21330] [Citation(s) in RCA: 15] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/26/2021] [Accepted: 10/12/2021] [Indexed: 11/27/2022] Open
Abstract
Background Various regional analgesia techniques are used to reduce postoperative pain in patients undergoing video-assisted thoracic surgery (VATS). This study aimed to determine the relative efficacy of regional analgesic interventions for VATS using a network meta-analysis. Methods We searched the Medline, EMBASE, Cochrane Controlled Trial Register, Web of Science, and Google Scholar databases to identify all randomized controlled trials (RCTs) that compared the analgesic effects of the following interventions: control, thoracic paravertebral block (TPVB), erector spinae plane block (ESPB), serratus plane block (SPB), and intercostal nerve block (INB). The primary outcome was opioid consumption during the first 24 h postoperative period. Pain scores were also collected during three different postoperative periods: the early (0–6 h), middle (6–18 h), and late (18–24 h) periods. Results A total of 21 RCTs (1,391 patients) were included. TPVB showed the greatest effect on opioid consumption compared with the control (mean difference [MD]: −13.2 mg, 95% CI [−16.2, −10.1]). In terms of pain scores in the early period, ESPB had the greatest effect compared to control (MD: −1.6, 95% CI [−2.3, −0.9]). In the middle and late periods, pain scores showed that TPVB, ESPB and INB had superior analgesic effects compared to controls, while SPB did not. Conclusions TPVB had the best analgesic efficacy following VATS, though the analgesic efficacy of ESPBs was comparable. However, further studies are needed to determine the optimal regional analgesia technique to improve postoperative pain control following VATS.
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Affiliation(s)
- Yumin Jo
- Department of Anesthesiology and Pain Medicine, Chungnam National University Hospital, Daejeon, Korea.,Department of Anesthesiology and Pain Medicine, College of Medicine, Chungnam National University, Daejeon, Korea
| | - Seyeon Park
- Department of Nursing, College of Nursing, Chungnam National University, Daejeon, Korea
| | - Chahyun Oh
- Department of Anesthesiology and Pain Medicine, Chungnam National University Hospital, Daejeon, Korea.,Department of Anesthesiology and Pain Medicine, College of Medicine, Chungnam National University, Daejeon, Korea
| | - Yujin Pak
- Department of Anesthesiology and Pain Medicine, Chungnam National University Hospital, Daejeon, Korea.,Department of Anesthesiology and Pain Medicine, College of Medicine, Chungnam National University, Daejeon, Korea
| | - Kuhee Jeong
- Department of Anesthesiology and Pain Medicine, Chungnam National University Hospital, Daejeon, Korea
| | - Sangwon Yun
- Department of Anesthesiology and Pain Medicine, Chungnam National University Hospital, Daejeon, Korea.,Department of Anesthesiology and Pain Medicine, College of Medicine, Chungnam National University, Daejeon, Korea
| | - Chan Noh
- Department of Anesthesiology and Pain Medicine, Chungnam National University Hospital, Daejeon, Korea.,Department of Anesthesiology and Pain Medicine, College of Medicine, Chungnam National University, Daejeon, Korea
| | - Woosuk Chung
- Department of Anesthesiology and Pain Medicine, Chungnam National University Hospital, Daejeon, Korea.,Department of Anesthesiology and Pain Medicine, College of Medicine, Chungnam National University, Daejeon, Korea
| | - Yoon-Hee Kim
- Department of Anesthesiology and Pain Medicine, Chungnam National University Hospital, Daejeon, Korea.,Department of Anesthesiology and Pain Medicine, College of Medicine, Chungnam National University, Daejeon, Korea
| | - Young Kwon Ko
- Department of Anesthesiology and Pain Medicine, Chungnam National University Hospital, Daejeon, Korea.,Department of Anesthesiology and Pain Medicine, College of Medicine, Chungnam National University, Daejeon, Korea.,Biomedical Research Institute, Chungnam National University Hospital, Daejeon, Korea
| | - Boohwi Hong
- Department of Anesthesiology and Pain Medicine, Chungnam National University Hospital, Daejeon, Korea.,Department of Anesthesiology and Pain Medicine, College of Medicine, Chungnam National University, Daejeon, Korea.,Biomedical Research Institute, Chungnam National University Hospital, Daejeon, Korea
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17
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Magone K, Ben-Ari E, Gyftopoulos S, Virk M. Pectoralis Major Tendon Tear: A Critical Analysis Review. JBJS Rev 2021; 9:01874474-202108000-00004. [PMID: 34415856 DOI: 10.2106/jbjs.rvw.20.00224] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/08/2023]
Abstract
» Pectoralis major (PM) tendon tears are predominantly seen in young men, and the majority of tears occur as tendon avulsions involving the sternal head. Weightlifting, specifically bench-pressing, and sporting activities with eccentric overloading of the PM tendon are the 2 most common activities that result in PM injury. » Early surgical repair or reconstruction should be offered to younger, active patients with a complete PM tear; the majority of the patients undergoing surgical repair achieve good-to-excellent outcomes. » Nonsurgical treatment of a complete PM tear is an option but will result in cosmetic deformity and a deficit in adduction strength of the arm. Outcomes after nonsurgical treatment of complete PM tears are less satisfactory than those obtained after surgical treatment. » Currently, there is no consensus on the chronological definition of PM tears (acute versus chronic), the critical time limit for performing surgical repair, the ideal fixation device (cortical button, bone tunnel, or suture anchors), the indications for allograft use, and the ideal rehabilitation protocol after treatment of PM tears.
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Affiliation(s)
- Kevin Magone
- Division of Shoulder and Elbow Surgery, Department of Orthopedic Surgery, NYU Grossman School of Medicine, NYU Langone Orthopedic Hospital, NYU Langone Health, New York, NY
- Shoulder and Elbow Surgery, CHI Saint Joseph Medical Group-Orthopedic Associates, CHI Saint Joseph Health, London, Kentucky
| | - Erel Ben-Ari
- Division of Shoulder and Elbow Surgery, Department of Orthopedic Surgery, NYU Grossman School of Medicine, NYU Langone Orthopedic Hospital, NYU Langone Health, New York, NY
- Division of Orthopaedic Surgery, Tel-Hashomer "Sheba" Medical Center, Sackler School of Medicine, Tel-Aviv University, Ramat Gan, Israel
| | - Soterios Gyftopoulos
- Department of Radiology, NYU Grossman School of Medicine, NYU Langone Health, New York, NY
| | - Mandeep Virk
- Division of Shoulder and Elbow Surgery, Department of Orthopedic Surgery, NYU Grossman School of Medicine, NYU Langone Orthopedic Hospital, NYU Langone Health, New York, NY
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18
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Chin KJ, Versyck B, Elsharkawy H, Rojas Gomez MF, Sala-Blanch X, Reina MA. Anatomical basis of fascial plane blocks. Reg Anesth Pain Med 2021; 46:581-599. [PMID: 34145071 DOI: 10.1136/rapm-2021-102506] [Citation(s) in RCA: 21] [Impact Index Per Article: 7.0] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/13/2021] [Revised: 01/29/2021] [Accepted: 01/30/2021] [Indexed: 11/04/2022]
Abstract
Fascial plane blocks (FPBs) are regional anesthesia techniques in which the space ("plane") between two discrete fascial layers is the target of needle insertion and injection. Analgesia is primarily achieved by local anesthetic spread to nerves traveling within this plane and adjacent tissues. This narrative review discusses key fundamental anatomical concepts relevant to FPBs, with a focus on blocks of the torso. Fascia, in this context, refers to any sheet of connective tissue that encloses or separates muscles and internal organs. The basic composition of fascia is a latticework of collagen fibers filled with a hydrated glycosaminoglycan matrix and infiltrated by adipocytes and fibroblasts; fluid can cross this by diffusion but not bulk flow. The plane between fascial layers is filled with a similar fat-glycosaminoglycan matric and provides gliding and cushioning between structures, as well as a pathway for nerves and vessels. The planes between the various muscle layers of the thorax, abdomen, and paraspinal area close to the thoracic paravertebral space and vertebral canal, are popular targets for ultrasound-guided local anesthetic injection. The pertinent musculofascial anatomy of these regions, together with the nerves involved in somatic and visceral innervation, are summarized. This knowledge will aid not only sonographic identification of landmarks and block performance, but also understanding of the potential pathways and barriers for spread of local anesthetic. It is also critical as the basis for further exploration and refinement of FPBs, with an emphasis on improving their clinical utility, efficacy, and safety.
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Affiliation(s)
- Ki Jinn Chin
- Department of Anesthesiology and Pain Medicine, Toronto Western Hospital, University of Toronto, Toronto, Ontario, Canada
| | - Barbara Versyck
- Department of Anaesthesia and Pain Medicine, Catharina Ziekenhuis, Eindhoven, North Brabant, The Netherlands.,Department of Anaesthesia and Pain Medicine, AZ Turnhout, Turnhout, Belgium
| | - Hesham Elsharkawy
- Outcomes Research Consortium, Cleveland Clinic, Cleveland, Ohio, USA.,Department of Anesthesiology, Case Western Reserve University, MetroHealth Pain and Healing Center, Cleveland, Ohio, USA
| | | | - Xavier Sala-Blanch
- Anesthesiology, Hospital Clinic de Barcelona, Barcelona, Spain.,Human Anatomy and Embryology, University of Barcelona Faculty of Medicine, Barcelona, Spain
| | - Miguel A Reina
- Department of Anesthesiology, Madrid-Monteprincipe University Hospital, CEU-San-Pablo University School of Medicine, Madrid, Spain
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19
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Boers N, Bleys RL, Schellekens PP. The nerve supply to the pectoralis major: An anatomical study and clinical application of the denervation in subpectoral breast implant surgery. J Plast Reconstr Aesthet Surg 2021; 75:415-423. [PMID: 34247965 DOI: 10.1016/j.bjps.2021.05.055] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/30/2020] [Revised: 04/09/2021] [Accepted: 05/27/2021] [Indexed: 10/21/2022]
Abstract
BACKGROUND Using the subpectoral approach, animation deformity or breast distortion due to pectoralis muscle contraction is common. Although the anatomy of the pectoral nerves has been extensively studied, only few studies have related the location of these nerves to bony landmarks. OBJECTIVE Our aim is to clarify the anatomy and possible variations of the innervation of the pectoralis major in relation to bony landmarks useful for surgery and to identify the preferred level for (selective) denervation by 1) transecting the nerves and 2) splitting the muscle in subpectoral breast implant surgery in cadavers. METHODS Fourteen pectoral regions (both left and right side) were dissected on 7 formaldehyde-fixed cadavers. The origin, locations, and course were mapped and (distances to) landmarks were reported. RESULTS The lateral pectoral nerve, medial pectoral nerve, and ansa pectoralis were identified in all cadavers. Nerve branches pierce the pectoralis minor or run along its upper or lower border. The piercing nerves vary from one to three branches and were consistently located lateral to the midclavicular line. The horizontal and vertical distances to bony landmarks varied greatly and depended on the size and location of the pectoralis minor, except for the nerve running along the upper border of the PMin, which was located consistently around 30% of the clavicular line from the acromioclavicular joint to the sternoclavicular joint. CONCLUSION We were unable to define a fixed landmark to mark pre- or peroperatively. However, we could define guidelines that help to identify and excise or preserve nerves of interest.
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Affiliation(s)
- Nadine Boers
- Department of Plastic, Reconstructive, and Hand Surgery, University Medical Center Utrecht, Utrecht, The Netherlands.
| | - Ronald Law Bleys
- Department of Anatomy, University Medical Center Utrecht, Utrecht, The Netherlands
| | - Pascal Pa Schellekens
- Department of Plastic, Reconstructive, and Hand Surgery, University Medical Center Utrecht, Utrecht, The Netherlands
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20
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Hong B, Bang S, Oh C, Park E, Park S. Comparison of PECS II and erector spinae plane block for postoperative analgesia following modified radical mastectomy: Bayesian network meta-analysis using a control group. J Anesth 2021; 35:723-733. [PMID: 33786681 DOI: 10.1007/s00540-021-02923-x] [Citation(s) in RCA: 13] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/11/2020] [Accepted: 03/13/2021] [Indexed: 12/29/2022]
Abstract
The present study compared the effects of pectoral nerve block II (PECS II) and erector spinae plane (ESP) block for postoperative analgesia in patients who underwent modified radical mastectomy by performing a network meta-analysis (NMA) using indirect comparison with systemic analgesia. Studies comparing the analgesic effects of PECS II and ESP block were searched on MEDLINE, PubMed, EMBASE and the Cochrane Library. The primary outcome of this study was cumulative opioid consumption for 24 h postoperatively. Pain score during this period was also assessed. NMA was performed to compare the postoperative analgesic effects of plane blocks and systemic analgesia. A search of databases identified 17 studies, with a total of 1069 patients, comparing the analgesic efficacies of PECS II block, ESP block, and systemic analgesia. Compared with systemic analgesia, mean difference of opioid consumption was - 10 mg (95% credible interval [CrI] - 15.0 to - 5.6 mg) with PECS II block and - 5.7 mg (95% CrI - 11.0 to - 0.7 mg) with ESP block. Relative to systemic analgesia, PECS II block showed lower pain scores over the first postoperative 24 h, whereas ESP block did not. PECS II block showed the highest surface under the cumulative ranking curves for both opioid consumption and pain score. Both PECS II and ESP blocks were shown to be more effective than systemic analgesia regarding postoperative analgesia following modified radical mastectomy, and between the two blocks, PECS II appeared to have favorable analgesic effects compared to ESP block.
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Affiliation(s)
- Boohwi Hong
- Department of Anesthesiology and Pain Medicine, Chungnam National University Hospital, Daejeon, Korea
- Department of Anesthesiology and Pain Medicine, College of Medicine, Chungnam National University, Daejeon, Korea
| | - Seunguk Bang
- Department of Anesthesiology and Pain Medicine, Daejeon St. Mary's Hospital, Daejeon, Korea
- Department of Anesthesiology and Pain Medicine, College of Medicine, The Catholic University of Korea, Seoul, Korea
| | - Chahyun Oh
- Department of Anesthesiology and Pain Medicine, Chungnam National University Hospital, Daejeon, Korea
| | - Eunhye Park
- Department of Anesthesiology and Pain Medicine, Chungnam National University Hospital, Daejeon, Korea
| | - Seyeon Park
- Department of Nursing, Chungnam National University, Daejeon, Korea.
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21
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Ciftci B, Ekinci M, Basim P, Celik EC, Tukac IC, Zenciroglu M, Atalay YO. Comparison of Ultrasound-Guided Type-II Pectoral Nerve Block and Rhomboid Intercostal Block for Pain Management Following Breast Cancer Surgery: A Randomized, Controlled Trial. Pain Pract 2021; 21:638-645. [PMID: 33710724 DOI: 10.1111/papr.13004] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/03/2020] [Revised: 02/18/2021] [Accepted: 03/05/2021] [Indexed: 10/21/2022]
Abstract
PURPOSE Although breast-conserving surgery-axillary dissection (BCS-AD) is a minimally invasive surgery, patients may suffer from moderate-to-severe pain. Several regional techniques can be used for pain control. The type II pectoral nerve block (PECS II) and the rhomboid intercostal block (RIB) are interfascial plane blocks that have been reported to provide effective analgesia after breast surgery. This study aims to compare the analgesic efficacy of the PECS II block and the RIB after breast surgery. PATIENTS AND METHODS Ninety female patients aged 18 to 65 years with American Society of Anesthesiologists (ASA) classes I and II physical status who underwent unilateral BCS-AD surgery were included. Patients were divided into three groups (n = 30 in each): the PECS II group, the RIB group, or the control group. PECS II block and RIB were performed with 30 mL 0.25% bupivacaine. Ibuprofen 400 mg IV 3 × 1 was given in the postoperative period. A patient control analgesia device included a dose of 10 µg/mL fentanyl, which was prepared and connected to the patients. RESULTS There were no statistical differences between groups in terms of demographical data. Postoperative fentanyl consumption was significantly lower in the PECS II and RIB groups than the control group. The need for rescue analgesia use was significantly higher in the control group than the other groups. At all times, visual analog scale scores were significantly lower in the PECS II and RIB groups than the control group. CONCLUSIONS The PECS II block and the RIB provide similar effective analgesia after BCS-AD.
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Affiliation(s)
- Bahadir Ciftci
- Department of Anesthesiology, School of Medicine, Istanbul Medipol University, Istanbul, Turkey
| | - Mursel Ekinci
- Department of Anesthesiology, Bursa State Hospital, Bursa, Turkey
| | - Pelin Basim
- Department of General Surgery, School of Medicine, Istanbul Medipol University, Istanbul, Turkey
| | - Erkan Cem Celik
- Department of Anesthesiology, School of Medicine, Erzurum Atatürk University, Erzurum, Turkey
| | - Ismail Cem Tukac
- Department of Anesthesiology, School of Medicine, Istanbul Medipol University, Istanbul, Turkey
| | - Mahmut Zenciroglu
- Department of General Surgery, School of Medicine, Istanbul Medipol University, Istanbul, Turkey
| | - Yunus Oktay Atalay
- Department of Anesthesiology, School of Medicine, Istanbul Medipol University, Istanbul, Turkey
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22
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Clavipectoral fascial plane block for implantable cardioverter defibrillator implantation. J Clin Anesth 2021; 71:110197. [PMID: 33601281 DOI: 10.1016/j.jclinane.2021.110197] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/02/2021] [Accepted: 02/04/2021] [Indexed: 11/20/2022]
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23
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Asghar A, Naaz S, Naya S. The prevalence and distribution of the variants of pectoralis minor in cadaveric studies: A systematic review and meta-analysis of 32 observational studies. NATIONAL JOURNAL OF CLINICAL ANATOMY 2021. [DOI: 10.4103/njca.njca_61_20] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/04/2022] Open
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Laumonerie P, Dalmas Y, Tibbo ME, Robert S, Faruch M, Chaynes P, Bonnevialle N, Mansat P. Sensory innervation of the human shoulder joint: the three bridges to break. J Shoulder Elbow Surg 2020; 29:e499-e507. [PMID: 32712453 DOI: 10.1016/j.jse.2020.07.017] [Citation(s) in RCA: 24] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/14/2020] [Revised: 06/29/2020] [Accepted: 07/07/2020] [Indexed: 02/01/2023]
Abstract
BACKGROUND Painful shoulders create a substantial socioeconomic burden and significant diagnostic challenge for shoulder surgeons. Consensus with respect to the anatomic location of sensory nerve branches is lacking. The aim of this literature review was to establish consensus with respect to the anatomic features of the articular branches (ABs) (1) innervating the shoulder joint and (2) the distribution of sensory receptors about its capsule and bursae. MATERIALS AND METHODS Four electronic databases were queried, between January 1945 and June 2019. Thirty original articles providing a detailed description of the distribution of sensory receptors about the shoulder joint capsule (13) and its ABs (22) were reviewed. RESULTS The suprascapular, lateral pectoral, axillary, and lower subscapular nerves were found to provide ABs to the shoulder joint. The highest density of nociceptors was found in the subacromial bursa. The highest density of mechanoreceptors was identified within the insertion of the glenohumeral ligaments. The most frequently identified innervation pattern comprised 3 nerve bridges (consisting of ABs from suprascapular, axillary, and lateral pectoral nerves) connecting the trigger and the identified pain generator areas rich in nociceptors. CONCLUSION Current literature supports the presence of a common sensory innervation pattern for the human shoulder joint. Anatomic studies have demonstrated that the most common parent nerves supplying ABs to the shoulder joint are the suprascapular, lateral pectoral, and axillary nerves. Further studies are needed to assess both the safety and efficacy of selective denervation of the painful shoulders, while limiting the loss of proprioceptive function.
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Affiliation(s)
- Pierre Laumonerie
- Department of Orthopaedic Surgery, Hôpital Pierre-Paul Riquet, Toulouse, France; Anatomy Laboratory, Faculty of Medicine, Toulouse, France.
| | - Yoann Dalmas
- Department of Orthopaedic Surgery, Hôpital Pierre-Paul Riquet, Toulouse, France
| | - Meagan E Tibbo
- Department of Orthopedic Surgery, Mayo Clinic, Rochester, MN, USA
| | - Suzanne Robert
- Department of Orthopaedic Surgery, Hôpital Pierre-Paul Riquet, Toulouse, France
| | - Marie Faruch
- Department of Radiology, Hôpital Pierre-Paul-Riquet, Toulouse, France
| | | | - Nicolas Bonnevialle
- Department of Orthopaedic Surgery, Hôpital Pierre-Paul Riquet, Toulouse, France
| | - Pierre Mansat
- Department of Orthopaedic Surgery, Hôpital Pierre-Paul Riquet, Toulouse, France
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Kent DT, Weiner JS, Chio EG, Weidenbecher M. Hypoglossal nerve stimulator implantation via a 2-incision technique. ACTA ACUST UNITED AC 2020. [DOI: 10.1016/j.otot.2020.06.002] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
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Mansour MA, Fouad AZ, Amin SM, Dobal NM. Establishing a Technique for Pectoral II-Block Catheter Insertion with Ultrasound Guidance: A Randomized Controlled Trial. Local Reg Anesth 2020; 13:85-93. [PMID: 32848451 PMCID: PMC7429189 DOI: 10.2147/lra.s262138] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/15/2020] [Accepted: 07/20/2020] [Indexed: 11/23/2022] Open
Abstract
Purpose To assess the efficacy and safety of a modified technique for ultrasound-guided pectoral II block for postoperative pain control after mastectomy. Methods In this randomized controlled trial, patients were randomly allocated into two groups (40 patients each). Group I patients were subjected to ultrasound-guided pectoral II block with injection of 10 mL lidocaine 1% as a dissecting solution before attempting catheter insertion, while group II patients underwent the standard procedure without a dissecting solution. Measured outcomes included catheter visibility, pain, patient satisfaction, performance time, and complications. Results Compared with group II, group I had significantly lower median catheter-visibility scores, shorter block performance time, and fewer insertion attempts. Group I had a nonsignificantly higher rate of complications than group II. Conclusion The modified technique facilitated the procedure, shortened the catheter-insertion time, and showed higher patient satisfaction. However, it was associated with lower catheter visibility on ultrasonography. Further studies are required to confirm the present findings and assess the safety of the modified technique.
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Affiliation(s)
- Mohamed A Mansour
- Department of Anesthesia, Intensive Care and Pain Management, Kasr Al Ainy Faculty of Medicine, Cairo University, Cairo, Egypt
| | - Ahmed Z Fouad
- Department of Anesthesia, Intensive Care and Pain Management, Kasr Al Ainy Faculty of Medicine, Cairo University, Cairo, Egypt
| | - Sarah M Amin
- Department of Anesthesia, Intensive Care and Pain Management, Kasr Al Ainy Faculty of Medicine, Cairo University, Cairo, Egypt
| | - Nasser M Dobal
- Department of Anesthesia, Intensive Care and Pain Management, Kasr Al Ainy Faculty of Medicine, Cairo University, Cairo, Egypt
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Desroches J, Roy M, Belliveau M, Leblanc B, Beaulieu P. [PECS I block for postoperative analgesia in patients undergoing breast augmentation surgery: a randomized double-blind placebo-controlled study]. Rev Bras Anestesiol 2020; 70:333-342. [PMID: 32792131 DOI: 10.1016/j.bjan.2020.04.013] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/08/2019] [Revised: 03/24/2020] [Accepted: 04/14/2020] [Indexed: 12/21/2022] Open
Abstract
BACKGROUND AND OBJECTIVES PECS I block was first described for surgery involving the pectoralis muscles. No randomized clinical trial has been conducted on surgeries that directly involve these muscles, such as subpectoral breast augmentation. We hypothesized that PECS I block would decrease pain in the postoperative period in this population. METHODS This was a randomized, double-blind, placebo-controlled trial in women undergoing subpectoral breast augmentation surgery. PECS I block was performed using 0.4 mL.kg-1 of 0.9% saline on one side and bupivacaine (0.25%) on the other side, each patient being her own control. Numeric Rating Scale (NRS) pain scores (0-10) were measured at rest and during movement. The primary outcome was pain score at rest 30 minutes after arrival in the PACU. To detect a clinically significant difference of 50% in pain reduction, 14 volunteers were enrolled (power of 90% and alpha<0.05). RESULTS In the PACU, three patients had no difference in pain between sides, five had reduced pain on the placebo side, and six had reduced pain on the bupivacaine side. In the bupivacaine group, pain scores at rest at 5, 30 and 60 minutes and 24 hours were 4.89 (4.23-5.56; mean 95% CI), 3.75 (3.13-4.37), 3.79 (2.93-4.64), and 2.29 (1.56-3.01), respectively, whereas in the placebo group, they were 4.96 (4.32-5.60), 4.00 (3.50-4.49), 3.93 (3.12-4.73), and 2.29 (1.56-3.01), respectively. CONCLUSIONS PECS I block in patients undergoing breast augmentation surgery does not provide better pain relief than placebo. Therefore, the indications for PECS I block in breast augmentation surgery should be reconsidered.
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Affiliation(s)
- Jean Desroches
- Clinique Chirurgicale de Laval, Department of Anesthesiology, Laval, Canada
| | - Maxim Roy
- Centre Hospitalier de l'Université de Montréal, Department of Anesthesiology, Montreal, Canada.
| | - Marc Belliveau
- Hôtel-Dieu de St Jérôme, Department of Anesthesiology, Saint-Jérôme, Canada
| | - Benoit Leblanc
- Clinique Chirurgicale de Laval, Department of Surgery, Laval, Canada
| | - Pierre Beaulieu
- Centre Hospitalier de l'Université de Montréal, Department of Anesthesiology, Montreal, Canada
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Pangthipampai P, Karmakar MK, Songthamwat B, Pakpirom J, Samy W. Ultrasound-Guided Multilevel Thoracic Paravertebral Block and Its Efficacy for Surgical Anesthesia During Primary Breast Cancer Surgery. J Pain Res 2020; 13:1713-1723. [PMID: 32765047 PMCID: PMC7367918 DOI: 10.2147/jpr.s246406] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/24/2020] [Accepted: 06/08/2020] [Indexed: 11/23/2022] Open
Abstract
Purpose Thoracic paravertebral block (TPVB), in conjunction with intravenous sedation, is reported to provide surgical anesthesia for primary breast cancer surgery (PBCS). Although ultrasound-guided (USG) TPVB has been described, there are no reports of USG multilevel TPVB for surgical anesthesia during PBCS. The aim of this prospective observational study was to determine the feasibility of performing USG multilevel TPVB, at the T1–T6 vertebral levels (6m-TPVB), and to evaluate its efficacy in providing surgical anesthesia for PBCS. Patients and Methods Twenty-five female patients undergoing PBCS received an USG 6m-TPVB for surgical anesthesia. Four milliliters of ropivacaine 0.5% (with epinephrine 1:200,000) was injected at each vertebral level. Dexmedetomidine infusion (0.1–0.5 µg.kg−1.h−1) was used for conscious sedation. Success of the block, for surgical anesthesia, was defined as being able to complete the PBCS without having to resort to rescue analgesia or convert to GA. Results The USG 6m-TPVB was successfully performed on all 25 patients but it was effective as the sole anesthetic in only 20% (5/25) of patients. The remaining 80% (20/25) reported pain during separation of the breast from the pectoralis major muscle and its fascia. Surgery was successfully completed using small doses of intravenous ketamine (mean total dose, 38.0±20.5 mg) as supplementary analgesia. Conclusion USG 6m-TPVB is technically feasible but does not consistently provide complete surgical anesthesia for PBCS that involves surgical dissection on the pectoralis major muscle and its fascia. Our data suggest that the pectoral nerves, which are not affected by a 6m-TPVB, are involved with afferent nociception.
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Affiliation(s)
- Pawinee Pangthipampai
- Department of Anesthesia and Intensive Care, The Chinese University of Hong Kong, Prince of Wales Hospital, Shatin, New Territories, Hong Kong Special Administrative Region of the People's Republic of China
| | - Manoj K Karmakar
- Department of Anesthesia and Intensive Care, The Chinese University of Hong Kong, Prince of Wales Hospital, Shatin, New Territories, Hong Kong Special Administrative Region of the People's Republic of China
| | - Banchobporn Songthamwat
- Department of Anesthesia and Intensive Care, The Chinese University of Hong Kong, Prince of Wales Hospital, Shatin, New Territories, Hong Kong Special Administrative Region of the People's Republic of China
| | - Jatuporn Pakpirom
- Department of Anesthesia and Intensive Care, The Chinese University of Hong Kong, Prince of Wales Hospital, Shatin, New Territories, Hong Kong Special Administrative Region of the People's Republic of China
| | - Winnie Samy
- Department of Anesthesia and Intensive Care, The Chinese University of Hong Kong, Prince of Wales Hospital, Shatin, New Territories, Hong Kong Special Administrative Region of the People's Republic of China
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Desroches J, Roy M, Belliveau M, Leblanc B, Beaulieu P. PECS I block for postoperative analgesia in patients undergoing breast augmentation surgery: a randomized double-blind placebo-controlled study. BRAZILIAN JOURNAL OF ANESTHESIOLOGY (ENGLISH EDITION) 2020. [PMID: 32792131 PMCID: PMC9373589 DOI: 10.1016/j.bjane.2020.07.004] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Indexed: 10/31/2022]
Abstract
Background and objectives Methods Results Conclusions
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Ince ME, Sir E, Eksert S, Ors N, Ozkan G. Analgesic Effectiveness of Ultrasound-Guided Pecs II Block in Central Venous Port Catheter Implantation. J Pain Res 2020; 13:1185-1191. [PMID: 32547181 PMCID: PMC7250288 DOI: 10.2147/jpr.s258692] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/17/2020] [Accepted: 05/14/2020] [Indexed: 11/23/2022] Open
Abstract
Background and Aim In oncology patients, central venous port catheter (CVPC) implantation is generally preferred for venous route. However, in this procedure, postoperative pain is often observed. This study aimed to investigate the effectiveness of ultrasound-guided Pecs II block in the management of pain after CVPC placement. Methods One hundred and eighty-seven patients who underwent CVPC implantation between January 2017 and August 2018 were included in the study. Patients who underwent Pecs II block under ultrasound guidance were called as the Pecs group, and those who underwent local anesthesia (LA) were referred as the LA group. All procedural parameters were analyzed, including demographic characteristics of patients, visual analogue scores (VAS) at 2nd and 24th hours, and postoperative opioid, and non-steroidal anti-inflammatory drug (NSAID) consumption. Results The postoperative 2nd hour VAS scores were similar in both groups and were lower than the 24th hour VAS scores. VAS scores at the 24th hour in the Pecs group were significantly lower than the LA group (P = 0.001). While the number of fentanyl rescue doses administered in PACU was similar, the total NSAID consumption in the first 24 hours was higher in the LA group than in the Pecs group. Conclusion In CVPC placement, ultrasound-guided Pecs II block is a more reliable, easily applicable and longer-acting approach than LA infiltration for postoperative analgesia.
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Affiliation(s)
- Mehmet Emin Ince
- Department of Anesthesiology and Reanimation, Gulhane Training and Research Hospital, University of Health Sciences, Ankara, Turkey
| | - Ender Sir
- Department of Algology and Pain Medicine, Gulhane Training and Research Hospital, University of Health Sciences, Ankara, Turkey
| | - Sami Eksert
- Department of Anesthesiology and Reanimation, Gulhane Training and Research Hospital, University of Health Sciences, Ankara, Turkey
| | - Nadide Ors
- Department of Anesthesiology and Reanimation, Gulhane Training and Research Hospital, University of Health Sciences, Ankara, Turkey
| | - Gokhan Ozkan
- Department of Anesthesiology and Reanimation, Gulhane Training and Research Hospital, University of Health Sciences, Ankara, Turkey
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Bois AJ, Lo IKY. Surgical anatomy of the pectoralis major tendon insertion revisited: relationship to nearby structures and the pectoral eminence for defining the anatomic footprint. JSES Int 2020; 4:324-332. [PMID: 32490421 PMCID: PMC7256899 DOI: 10.1016/j.jseint.2020.02.010] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/24/2022] Open
Abstract
Background Intraoperative identification of the normal pectoralis major (PM) footprint can be challenging to identify in the acute and chronic settings. The purpose of this study was to revisit the anatomic footprint of the PM tendon and to determine which nearby landmarks can be used to re-create the normal insertion site during anatomic repair or reconstruction. Methods Twenty-one fresh-frozen human cadaveric shoulder specimens were used to define the PM tendon width (ie, superior-to-inferior) and to determine the relationship between the superior aspect of the PM insertion and that of the latissimus dorsi (LD) and anterior deltoid (AD) tendons. An attempt was made to identify potential useful bony landmarks that can be used during anatomic repair or reconstruction of the PM tendon. Results The mean PM tendon width was 68.8 ± 4.4 mm. The superior margin of the LD insertion was 9.4 ± 5.9 mm above and the AD was 48.4 ± 7.1 mm below the superior margin of the PM tendon insertion, respectively. In 17 of 21 specimens (81%), the superior insertion of the PM tendon attached onto a bony prominence, named the pectoral eminence. Conclusions The LD and AD tendon insertions represent reliable soft tissue landmarks for identifying the superior extent of the PM tendon along its bony footprint. The pectoral eminence can also be used as an additional reference point in the majority of cases to facilitate anatomic restoration of the pectoralis tendon during repair and reconstruction. Surgeons should be familiar with the proximity of nearby neurovascular structures when performing PM repairs.
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Affiliation(s)
- Aaron J Bois
- Section of Orthopaedic Surgery, Department of Surgery, Cumming School of Medicine, University of Calgary, Calgary, AB, Canada.,Investigation Performed at the McCaig Institute for Bone and Joint Health, University of Calgary, Calgary, AB, Canada
| | - Ian K Y Lo
- Section of Orthopaedic Surgery, Department of Surgery, Cumming School of Medicine, University of Calgary, Calgary, AB, Canada.,Investigation Performed at the McCaig Institute for Bone and Joint Health, University of Calgary, Calgary, AB, Canada
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Abstract
Background: Pectoralis major ruptures are increasing in incidence primarily due to an increase in awareness, activity level among young males between 20 and 40 years of age, and use of anabolic steroids. Although the majority of pectoralis major ruptures are acute injuries, many chronic ruptures are unrecognized and it is imperative to understand the proper evaluation of these injuries, as well as the appropriate treatment for acute and chronic ruptures.Purpose: Pectoralis major ruptures can lead to deformity and physical disability if left untreated. This review paper discusses both acute and chronic ruptures as well as indications for nonoperative treatment and operative treatment to give the reader the best understanding of this diagnosis and proper management.Methods: A systematic review of the literature was performed using a search of electronic databases. Search terms such as pectoralis major rupture, pectoralis major repair, pectoralis major tendon transfer, and pectoralis major nonoperative treatment were used. Case reports, systematic reviews, prospective and retrospective studies were included to provide a comprehensive review. The only exclusion criteria consisted of studies not published in English. This review article includes the anatomy and biomechanics of the pectoralis major muscle, proper evaluation of the patient, operative and nonoperative treatment of acute and chronic pectoralis major ruptures, and outcomes of the recommended treatment.Conclusion: Nonoperative treatment is indicated for patients with medical comorbidities, older age, incomplete tears, or irreparable damage. Patients treated non-operatively have been shown to lose strength, but regain full range of motion. Patients with surgery before 6 weeks reported better outcomes than patients with surgery between 6 and 8 weeks. The chronicity of the rupture (>8 weeks) increases the likelihood of reconstruction, involving the use of autografts or allografts. Patients treated with delayed repair had significantly better strength, satisfaction, and outcomes than patients with nonoperative treatment. The pectoralis tendon can also be transferred in patients with rotators cuff tears, atrophy, or significant functional limitation. Tendon transfers have been shown to have unpredictable outcomes, but overall satisfactory results.
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Affiliation(s)
- Kamali Thompson
- Division of Sports Medicine, Department of Orthopaedic Surgery, NYU Langone Health, New York, NY
| | - Young Kwon
- Division of Sports Medicine, Department of Orthopaedic Surgery, NYU Langone Health, New York, NY
| | - Evan Flatow
- Department of Orthopaedic Surgery, The Mount Sinai Hospital, New York, NY, USA
| | - Laith Jazrawi
- Division of Sports Medicine, Department of Orthopaedic Surgery, NYU Langone Health, New York, NY
| | - Eric Strauss
- Division of Sports Medicine, Department of Orthopaedic Surgery, NYU Langone Health, New York, NY
| | - Michael Alaia
- Division of Sports Medicine, Department of Orthopaedic Surgery, NYU Langone Health, New York, NY
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Leijnse JN, de Bakker BS, D'Herde K. The brachial plexus - explaining its morphology and variability by a generic developmental model. J Anat 2019; 236:862-882. [PMID: 31814126 DOI: 10.1111/joa.13123] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/27/2019] [Revised: 10/23/2019] [Accepted: 10/30/2019] [Indexed: 12/01/2022] Open
Abstract
In classic anatomy teaching, the brachial plexus generally features as an enigmatic rote-learned structure, leaving the student with a feeling of complexity. The notion of complexity may increase in dissections, where plexuses significantly differing from the standard plexus model are readily found. This raises questions: what determines the existence and prevalence of variants and to what degree should they be considered anomalous? A model linking brachial plexus morphology and its variability to causative morphological parameters which would also standardize plexus description and teaching would be beneficial. The present study aims to provide such a model by analyzing the context of plexus development and applying this model in the analysis of plexus variability in anatomical specimens. Based on a thorough literature review, a generic developmental model was formulated and different factors of variability defined. In 56 plexuses, the proposed generic principles of plexus variability were found consistent with the variations encountered. Summarized, the modeled generic principles are as follows. Brachial plexus axon bundles grow out into an environment of chemical tracer paths in which constraints and obstacles are present: the geometry of the arm bud, cartilaginous bone precursors and vessels. The overall constancy of these factors generates a gross plexus outline, while the variability in these factors gives rise to typical plexus variations. The usefulness of the model derives from the fact that the variability of the main morphologically determining factors is not random but is the expression of the possibilities of the embryological substrate. Within the model, the major plexus morphological determinant is the segmental position of the subclavian artery, which is determined by the segment level of the intersegmental artery from which it develops. Normally, the subclavian artery develops from intersegmental artery i7. However, the subclavian artery can develop from inferior or superior segmental levels, from intersegmental artery i8 or i6, and possibly also from i9 or i5. Each of these arterial variants creates a typical, morphologically distinct, predictable plexus configuration. Superimposed on these basic plexus configurations, the underlying embryological substrate may develop further variability by integrating remnants of other intersegmental arteries into the arterial network. The resulting plexus configurations are further modified by local factors, e.g. the splitting of outgrowing axon bundles around vessels. A large split in the lateral cord around a large vein or veins crossing from lateral to medial, tangentially cranially over the subclavian artery was found in 54% of the 56 investigated BP and therefore might be added to plexus teaching. The distinct plexus morphologies associated with the subclavian artery segmental levels were further found associated with, among others, typical variations in the pectoral nerves and their ansas; these associations were also modeled. The presented models could allow brachial plexus rote learning to be replaced by a more insightful narrative of formative principles suitable for teaching. Clinically, improved understanding of the relationship between plexus variability and the local anatomical environment should be relevant to brachial plexus surgery and reconstruction.
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Affiliation(s)
- Joris N Leijnse
- Department of Human Structure and Repair, Faculty of Medicine and Health Sciences, University of Ghent, Ghent, Belgium
| | - Bernadette S de Bakker
- Department of Medical Biology, Section Clinical Anatomy & Embryology, Amsterdam UMC, University of Amsterdam, Amsterdam, The Netherlands
| | - Katharina D'Herde
- Department of Human Structure and Repair, Faculty of Medicine and Health Sciences, University of Ghent, Ghent, Belgium
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Hayes SM, El Raouf RA, El Metwally Farahat T, El Deen Hamed E. Efficacy of adding tramadol as adjunctive analgesic with levobupivacaine in modified pectoral nerve block for modified radical mastectomy surgery. EGYPTIAN JOURNAL OF ANAESTHESIA 2019. [DOI: 10.1016/j.egja.2017.08.005] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022] Open
Affiliation(s)
- Salwa M.S. Hayes
- Department of Anesthesia and Intensive Care, Mansoura University, Faculty of Medicine, Egypt
| | - Reem Abd El Raouf
- Department of Anesthesia and Intensive Care, Mansoura University, Faculty of Medicine, Egypt
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Schuitemaker R JB, Sala-Blanch X, Sánchez Cohen AP, López-Pantaleon LA, Mayoral R JT, Cubero M. Analgesic efficacy of modified pectoral block plus serratus plane block in breast augmentation surgery: A randomised, controlled, triple-blind clinical trial. ACTA ACUST UNITED AC 2018; 66:62-71. [PMID: 30674430 DOI: 10.1016/j.redar.2018.08.001] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/06/2017] [Revised: 08/08/2018] [Accepted: 08/09/2018] [Indexed: 11/27/2022]
Abstract
INTRODUCTION Prosthetic breast surgery is a very common plastic surgery procedure, but its postoperative analgesic management is a challenge for the surgical team. The purpose of the present study is to validate the analgesic efficacy of pectoral block and serratus plane block in retropectoral mammoplasty. PATIENTS AND METHODS A randomised, controlled, triple-blind, clinical trial was designed, and included 30 patients undergoing retropectoral augmentation mammoplasty. All of them had a modified PECII block and a serratus plane block with a total volume of 40ml per breast. In 15 of them bupivacaine 0.25% (GPEC) was injected and in the other 15 patients saline was used (GC). Standardised management of anaesthesia and postoperative analgesia was performed. Intra-operative haemodynamic parameters required for postoperative analgesia, and a numeric verbal scale on arrival in the recovery unit were measured and at 3, 6, and 24h. The quality perceived by patients and surgeons was also measured. RESULTS Post-operative pain was significantly better in GPEC (5.3±2.3 vs. 2.9±2.7; P=.018). No significant differences were observed at 3, 6, and 24h. The surgeons rated the anaesthetic-analgesic quality as very good in 80% of the cases in GPEC versus 33% in CG (P=.01). CONCLUSIONS The use of these blocks is a good perioperative analgesic strategy in the multimodal management of retropectoral augmentation mammoplasty.
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Affiliation(s)
- J B Schuitemaker R
- Servicio de Anestesiología, Reanimación y Terapéutica del Dolor, QuironSalud Hospital Universitari General de Catalunya e Hypnos S.L.P., Sant Cugat del Vallès, Barcelona, España.
| | - X Sala-Blanch
- Servicio de Anestesiología, Reanimación y Terapéutica del Dolor, Hospital Clínic de Barcelona, Departamento de Anatomía Humana, Universitat de Barcelona, Barcelona, España
| | - A P Sánchez Cohen
- Servicio de Radiología Intervencionista, Invenciones Tecnológicas en Medicina (INTEM), QuironSalud Hospital Universitari General de Catalunya, Sant Cugat del Vallès, Barcelona, España
| | - L A López-Pantaleon
- Servicio de Anestesiología, Reanimación y Terapéutica del Dolor, QuironSalud Hospital Universitari General de Catalunya e Hypnos S.L.P., Sant Cugat del Vallès, Barcelona, España
| | - J T Mayoral R
- Servicio de Anestesiología, Reanimación y Terapéutica del Dolor, QuironSalud Hospital Universitari General de Catalunya e Hypnos S.L.P., Sant Cugat del Vallès, Barcelona, España
| | - M Cubero
- Sección de Estadística, Facultad de Biología, Universitat de Barcelona, Barcelona, España
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Rahimzadeh P, Imani F, Faiz SHR, Boroujeni BV. Impact of the Ultrasound-Guided Serratus Anterior Plane Block on Post-Mastectomy Pain: A Randomised Clinical Study. Turk J Anaesthesiol Reanim 2018; 46:388-392. [PMID: 30263863 DOI: 10.5152/tjar.2018.86719] [Citation(s) in RCA: 37] [Impact Index Per Article: 6.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/03/2018] [Accepted: 05/19/2018] [Indexed: 11/22/2022] Open
Abstract
Objective A variety of methods, including neuraxial and regional blocks, have been used to manage post-mastectomy pain. This study evaluates the effect of serratus anterior plane block on acute pain after mastectomy. Methods A total of 60 patients who were candidates for mastectomy under general anaesthesia were divided in this trial into two groups. After entering the recovery room, the first-experimental-group (SAB) underwent the ultrasound-guided serratus anterior block, but the second-control-group (CTL) received no block intervention. An intravenous patient-controlled analgesia (PCA) device was used to deliver fentanyl in both groups. Using the Visual Analog Scale (VAS), the patients' pain was assessed at intervals of 1, 6, 12 and 24 hours after entering the recovery room. Intravenous acetaminophen was administered as a rescue analgesic if the pain exceeded 3 on the VAS. A total amount of fentanyl consumed, the time to first PCA request, a total amount of acetaminophen consumption and possible adverse effects were evaluated. Results The pain scores assessed at the time intervals were not significantly different between the two groups (p>0.5). The total consumption of fentanyl was significantly lower in the SAB group than in the CTL group (p=0.0001). Duration of the time to first PCA request was remarkably longer in the SAB group than in the CTL group (p=0.0001). The total amount of acetaminophen consumed was notably higher in the CTL group than in the SAB group (p=0.001). None of the patients experienced side effects. Conclusion Undertaking serratus anterior block following mastectomy can reduce pain scores and lower opioid usage.
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Affiliation(s)
- Poupak Rahimzadeh
- Pain Research Center, Iran University of Medical Sciences, Tehran, Iran
| | - Farnad Imani
- Pain Research Center, Iran University of Medical Sciences, Tehran, Iran
| | - Seyed Hamid Reza Faiz
- Rasoul Akram Hospital Clinical Research Development Center, Iran University of Medical Sciences, Tehran, Iran
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Pectoral Block Failure May Be Due to Incomplete Coverage of Anatomical Targets: A Dissection Study. Reg Anesth Pain Med 2018; 43:844-848. [PMID: 30095696 DOI: 10.1097/aap.0000000000000837] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
BACKGROUND AND OBJECTIVES The popularization of ultrasound-guided nerve blocks in cosmetic and reconstructive breast surgery calls for better anatomical understanding of chest wall innervation. When inserting subpectoral implants, pain from pocket dissection, stretching of muscle, and release of costal attachments may be relieved by blocking the pectoral nerves in the interpectoral (IP) space.We describe the variable anatomy of the pectoral nerves in the IP space in order to define the area to be covered for sufficient blockade, based on cadaver dissections. METHODS Twenty-six fresh cadavers were dissected bilaterally. The number, location, and course of the pectoral nerves were recorded. Distances to surface landmarks (sternum, clavicle, and costae) and ultrasound landmarks (thoracoacromial artery [TAA] and pectoralis minor muscle [Pm]) were recorded. RESULTS The lateral pectoral nerve and the TAA entered together into the IP space 8.9 cm (range, 8.0-12.0 cm) lateral to the midsternal line. The medial pectoral nerve (MPN) had between 1 and 4 branches that pierced the Pm, and 69% had additional branches lateral to the Pm. The muscle-piercing MPN branches were located 3.8 cm (range, 0.4-8.1 cm) and the lateral MPN branches 5.4 cm (range, 3.0-8.4 cm) from the lateral pectoral nerve. The IP course was 2.6 cm (range, 0.7-6.5 cm). All specimens were asymmetrical in location or number of MPN branches. CONCLUSIONS The MPN branches that innervate the lower part of the pectoralis major muscle are asymmetrical and variable in location and length; all located in a triangular area easily defined by sonographic landmarks, lateral to the TAA.
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Efficacy of Pectoral Nerve Block Type II for Breast-Conserving Surgery and Sentinel Lymph Node Biopsy: A Prospective Randomized Controlled Study. Pain Res Manag 2018; 2018:4315931. [PMID: 29861803 PMCID: PMC5976903 DOI: 10.1155/2018/4315931] [Citation(s) in RCA: 46] [Impact Index Per Article: 7.7] [Reference Citation Analysis] [Abstract] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/02/2018] [Accepted: 04/16/2018] [Indexed: 11/17/2022]
Abstract
Objectives The pectoral nerve block type II (PECS II block) is widely used for postoperative analgesia after breast surgery. This study evaluated the analgesic efficacy of PECS II block in patients undergoing breast-conserving surgery (BCS) and sentinel lymph node biopsy (SNB). Methods Patients were randomized to the control group (n=40) and the PECS II group (n=40). An ultrasound-guided PECS II block was performed after induction of anesthesia. The primary outcome measure was opioid consumption, and the secondary outcome was pain at the breast and axillary measured using the Numerical Rating Scale (NRS) 24 hours after surgery. Opioid requirement was assessed according to tumor location. Results Opioid requirement was lower in the PECS II than in the control group (43.8 ± 28.5 µg versus 77.0 ± 41.9 µg, p < 0.001). However, the frequency of rescue analgesics did not differ between these groups. Opioid consumption in the PECS II group was significantly lower in patients with tumors in the outer area than that in patients with tumors in the inner area (32.5 ± 23.0 µg versus 58.0 ± 29.3 µg, p=0.007). The axillary NRS was consistently lower through 24 hr in the PECS II group. Conclusion Although the PECS II block seemed to reduce pain intensity and opioid requirements for 24 h after BCS and SNB, these reductions may not be clinically significant. This trial is registered with Clinical Research Information Service KCT0002509.
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Sneag DB, Lee SC, Feinberg JH, Melisaratus DP, Amber I. Magnetic resonance imaging patterns of mononeuropathic denervation in muscles with dual innervation. Skeletal Radiol 2017; 46:1657-1665. [PMID: 28755280 DOI: 10.1007/s00256-017-2734-2] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/05/2017] [Revised: 06/28/2017] [Accepted: 07/14/2017] [Indexed: 02/02/2023]
Abstract
Magnetic resonance imaging (MRI) of mononeuropathy in muscles with dual innervation depicts geographic denervation corresponding to the affected nerve. Knowledge of the normal distribution of a muscle's neural supply is clinically relevant as partial muscle denervation represents a potential imaging pitfall that can be confused with other pathology, such as muscle strain. This article reviews the normal innervation pattern of extremity muscles with dual supply, providing illustrative examples of mononeuropathy affecting such muscles.
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Affiliation(s)
- Darryl B Sneag
- Department of Radiology and Imaging, Hospital for Special Surgery, New York, NY, USA
| | - Susan C Lee
- Department of Radiology and Imaging, Hospital for Special Surgery, New York, NY, USA.
| | - Joseph H Feinberg
- Hospital for Special Surgery, Physical Medicine and Rehabilitation, New York, NY, USA
| | - Darius P Melisaratus
- Department of Radiology and Imaging, Hospital for Special Surgery, New York, NY, USA
| | - Ian Amber
- Department of Radiology, MedStar Georgetown University Hospital, DC, Washington, USA
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Pectoralis Major Injuries: Return to Play Potential. CURRENT PHYSICAL MEDICINE AND REHABILITATION REPORTS 2017. [DOI: 10.1007/s40141-017-0154-9] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/19/2022]
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The PECS II block as a major analgesic component for clavicle operations: A description of 7 case reports. ACTA ACUST UNITED AC 2017; 65:53-58. [PMID: 28554710 DOI: 10.1016/j.redar.2017.04.005] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/24/2017] [Revised: 04/12/2017] [Accepted: 04/14/2017] [Indexed: 11/21/2022]
Abstract
Clavicle fractures correspond to 35% of traumatic fractures of the shoulder girdle. Regional anaesthesia has shown better analgesic results than systemic treatment for perioperative management. Innervation of the clavicle is complex, at present its knowledge raises controversy. The lateral pectoral nerve through the innervating musculature predominantly participates in the lateral and anterior part of the clavicle. The following report of 7 cases describes the effective postoperative analgesia of modified PEC II block in patients with middle third clavicle fracture or acromioclavicular dislocation who underwent a modified PEC II block for postoperative pain management, in the context of a multimodal analgesia. The potential advantage of this management over other analgesic procedures should be evaluated in specific clinical trials.
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Fajardo-Pérez M, Altınpulluk EY, García-Miguel J, Quintana-Gordon B. Ultrasound-Guided Continuous Interpectoral Block for Patient Undergoing Mastectomy and Axillary Clearance. Turk J Anaesthesiol Reanim 2017; 45:112-115. [PMID: 28439445 DOI: 10.5152/tjar.2017.43815] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/04/2016] [Accepted: 01/20/2017] [Indexed: 11/22/2022] Open
Abstract
Using a single dose of local anaesthetics has some disadvantages and provides limited analgesia depending on the pharmacokinetic characteristics of the local anaesthetic used. Nevertheless, the use of continuous perineural infusions allows sustained pain control. Ultrasound-guided interpectoral block followed by the placement of catheters in patients undergoing mastectomies with or without lymph node axillary dissections can result in sufficient pain control. We present a case of a 58-year-old woman undergoing mastectomy and axillary clearance who received ultrasound-guided continuous interpectoral block for postoperative analgesia. After the induction of general anaesthesia, interpectoral ultrasound block was performed and levobupivacaine was administered through a catheter placed between the pectoralis minor and pectoralis major muscles using an ultrasound-guided technique. We used an elastomeric pump containing the 0.125% levobupivacaine anaesthetic solution, with an infusion rate of 5 mL h-1 for 48 h. Excellent postoperative pain control was observed. Local anaesthetic- and catheter-related side-effects were not observed. The ideal infusion rate for interpectoral block in patients under mastectomy has not been determined. More randomised studies are needed to confirm whether interpectoral techniques are appropriate for routine clinical practice.
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Affiliation(s)
| | - Ece Yamak Altınpulluk
- Department of Anesthesiology, İstanbul University Cerrahpaşa School of Medicine, İstanbul, Turkey
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Motor Nerve Preservation and Muscle Atrophy After Pectoralis Major Musculocutaneous Flap Surgery for Oromandibular Reconstruction. J Craniofac Surg 2016; 27:2055-2060. [PMID: 28005753 DOI: 10.1097/scs.0000000000002969] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022] Open
Abstract
OBJECTIVE The authors investigated the clinical and histopathologic significance of medial pectoral nerve preservation/reinnervation of pectoralis major musculocutaneous flap for oromandibular reconstruction. MATERIALS AND METHODS The authors compared 13 patients treated with pectoralis major musculocutaneous flap reconstruction and 6 control patients treated by rectus abdominis musculocutaneous flap reconstruction without motor nerve restoration. Subjective awareness was scored to evaluate changes in the facial contour due to muscle atrophy, and objective evaluation was performed in few patients. In addition, the authors performed histopathologic analysis of both muscle atrophy and nerve regeneration in 20 patients from whom samples were available. RESULTS Subjective awareness of changes in the facial contour induced by muscle atrophy was low among patients with nerve preservation/reinnervation, but there were objective changes at 3 months after surgery among patients who underwent nerve resection. In the patients who had medial pectoral nerve preservation or nerve restoration by nerve suture, favorable facial symmetry was retained at 5 years after surgery. Even though the motor nerve was preserved or restored, fatty degeneration and fibrosis were noted in approximately 30% of the total surface area of the muscle, and type I fibers had decreased to 36% that of control at 7 years after surgery. However, regressive changes were inhibited for 1 year after surgery; in contrast, changes corresponding to those noted at 7 years after surgery were observed by 3 months in the patients with nerve resection. CONCLUSION Thus, the authors showed that preservation or restoration of nerves can delay muscle and have highlighted the potential benefits of this approach.
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Li NL, Yu BL, Hung CF. Paravertebral Block Plus Thoracic Wall Block versus Paravertebral Block Alone for Analgesia of Modified Radical Mastectomy: A Retrospective Cohort Study. PLoS One 2016; 11:e0166227. [PMID: 27829018 PMCID: PMC5102399 DOI: 10.1371/journal.pone.0166227] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/25/2016] [Accepted: 10/17/2016] [Indexed: 11/18/2022] Open
Abstract
BACKGROUND AND OBJECTIVES Paravertebral block placement was the main anesthetic technique for modified radical mastectomy in our hospital until February 2014, when its combination with blocks targeting the pectoral musculature was initiated. We compared the analgesic effects of paravertebral blocks with or without blocks targeting the pectoral musculature for modified radical mastectomy. METHODS We retrospectively collected data from a single surgeon and anesthesiologist from June 1, 2012, to May 31, 2015. Intraoperative sedatives and analgesic requirements, time to the first analgesic request, postoperative analgesic doses, patient satisfaction, and complications were compared. RESULTS Fifty-four patients received a paravertebral block alone (PECS 0), and 46 received a paravertebral block combined with blocks targeting the pectoral musculature (PECS 1). The highest intraoperative effect-site concentration of propofol was significantly lower in the PECS 1 group than in the PECS 0 group [2.3 (1.5, 2.8) vs 2.5 (1.5, 4) μg/mL, p = 0.0014]. The intraoperative rescue analgesic dose was significantly lower in the PECS 1 group [0 (0, 25) vs 0 (0, 75) mg of ketamine, p = 0.0384]. Furthermore, the PECS 1 group had a significantly longer time to the first analgesic request [636.5 (15, 720) vs 182.5 (14, 720) min, p = 0.0001]. After further adjustment for age, body mass index, American Society of Anesthesiologists Physical Status classification, chronic pain history, incidence of a superficial cervical plexus block placement, and operation duration, blocks targeting the pectoral musculature were determined to be the only significant factor (hazard ratio, 0.36; 95% confidence interval, 0.23-0.58; p < 0.0001). Very few patients used potent analgesics including morphine and ketorolac; the cumulative use of morphine or ketorolac was similar in the study groups. However, the incidence of all analgesic use, namely morphine, ketorolac, acetaminophen, and celecoxib, was significantly lower in the PECS 1 group [3.5 (0, 6) vs 5 (0, 12), p < 0.0001]. CONCLUSIONS Compared with the placement of a paravertebral block alone, combining blocks targeting the pectoral musculature with a paravertebral block for modified radical mastectomy reduced the sedative and analgesic requirements during operation and provided more effective postoperative analgesia.
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Affiliation(s)
- Nai-Liang Li
- Department of Anesthesiology, Koo Foundation Sun Yat-Sen Cancer Center, Taipei, Taiwan, Republic of China
| | - Ben-Long Yu
- Department of Surgery, Koo Foundation Sun Yat-Sen Cancer Center, Taipei, Taiwan, Republic of China
| | - Chen-Fang Hung
- Biostatistics Section, Office of Clinical Research, Koo Foundation Sun Yat-Sen Cancer Center, Taipei, Taiwan, Republic of China
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Hanna A. The SPA arrangement of the branches of the upper trunk of the brachial plexus: a correction of a longstanding misconception and a new diagram of the brachial plexus. J Neurosurg 2016; 125:350-4. [DOI: 10.3171/2015.5.jns15367] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
Abstract
OBJECT
Brachial plexus (BP) diagrams in most textbooks and papers represent the branches and divisions of the upper trunk (UT) in the following sequence from cranial to caudal: suprascapular nerve, anterior division, and then posterior division. This concept contradicts what is seen in the operating room and is noticed by most peripheral nerve surgeons. This cadaveric study was conducted to look specifically at the exact pattern of branching of the upper trunk of the BP.
METHODS
Ten cadavers (20 BPs) were dissected. Both supra- and infraclavicular exposures were performed. The clavicle was retracted or resected to identify the divisions of the BP. A posterior approach was used in 2 cases.
RESULTS
In all dissections the origin of the posterior division was in a more cranial and dorsal plane in relation to the anterior division. In most dissections the supra scapular nerve branched off distally from the UT, giving it the appearance of a trifurcation, taking off just cranial and dorsal to the posterior division. The branching pattern of the UT consistently had the following sequential arrangement from cranial and posterior to caudal and anterior: suprascapular nerve (S), posterior division (P), and anterior division (A), hence the acronym SPA.
CONCLUSIONS
Supraclavicular exposure of the BP exposes only the trunks and divisions. Recognizing the “SPA” arrangement of the branches helps in identifying the correct targets for neurotization, especially given that these 3 branches are the most common targets for BP repair. Understanding the anatomy means better surgical planning and better patient outcomes.
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Abstract
The knowledge of innervation of pectoral muscles is important to surgeons performing breast surgeries, axillary lymph node dissection, harvesting pectoralis major/minor for flaps, and during neurotization procedures where the pectoral nerves are particularly at risk. The present case describes the innervation of the pectoral muscles solely by a nerve trunk arising from the ansa pectoralis (AP) - the loop of medial and lateral pectoral nerves. Interestingly, there was also a communication between the AP and roots forming the median nerve. It is imperative for the operating surgeons to be aware of these rare variations in order to prevent denervation and subsequent atrophy of the pectoral musculature.
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Affiliation(s)
- Sarika Rachel Tigga
- Department of Anatomy, ESIC Medical College and Hospital, NIT, NH3, Faridabad, Haryana, India
| | - Surbhi Wadhwa
- Department of Anatomy, Maulana Azad Medical College, New Delhi, India
| | - Preeti Goswami
- Department of Anatomy, Maulana Azad Medical College, New Delhi, India
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Chakraborty A, Khemka R, Datta T. Ultrasound-guided truncal blocks: A new frontier in regional anaesthesia. Indian J Anaesth 2016; 60:703-711. [PMID: 27761032 PMCID: PMC5064693 DOI: 10.4103/0019-5049.191665] [Citation(s) in RCA: 34] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/08/2023] Open
Abstract
The practice of regional anaesthesia is rapidly changing with the introduction of ultrasound into the working domain of the anaesthesiologist. New techniques are being pioneered. Among the recent techniques, notable are the truncal blocks, for example, the transversus abdominis plane block, rectus sheath block, hernia block and quadratus lumborum block in the abdomen and the pectoral nerves (Pecs) block 1 and 2, serratus anterior plane block and intercostal nerve block. This narrative review covers the brief anatomical discourse along with technical description of the ultrasound-guided truncal blocks.
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Affiliation(s)
| | - Rakhi Khemka
- Tata Medical Center, Kolkata, West Bengal, India
| | - Taniya Datta
- Tata Medical Center, Kolkata, West Bengal, India
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Bolin ED, Harvey NR, Wilson SH. Regional Anesthesia for Breast Surgery: Techniques and Benefits. CURRENT ANESTHESIOLOGY REPORTS 2015. [DOI: 10.1007/s40140-015-0102-0] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/17/2022]
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Affiliation(s)
- R. Fuzier
- Institut Universitaire du Cancer Toulouse Oncopole; Toulouse France
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