Brachial plexus anesthesia: A review of the relevant anatomy, complications, and anatomical variations

Ultrasound accuracy for brachial plexus pathology

AIM

To determine (a) the accuracy of ultrasound in detecting brachial plexus pathology and (b) outline the advantages and limitations of ultrasound compared to MRI for imaging the brachial plexus.

MATERIAL AND METHODS

cases with clinically suspected brachial plexus pathology were evaluated first by ultrasound, followed by MRI. Patients with prior brachial plexus imaging were excluded. The final diagnosis was based on a combination of ultrasound, MRI, clinical follow-up, and surgical findings. The accuracy of the ultrasound was assessed by comparing the ultrasound and the final diagnoses. The mean clinical follow-up time following ultrasound was 1.8 ± 1.4 years.

RESULTS

Ninety-two (64%) of the 143 cases had normal brachial plexus ultrasound and MRI examinations. Fifty-one (36%) of 143 cases had brachial plexus pathology on MRI, comprising post-radiation fibrosis (n=25, 49%), nerve sheath tumor (n=11, 21%), traumatic injury (n=7, 14%), inflammatory polyneuropathy (n=4, 8%), malignant infiltration (n=2, 4%), desmoid fibromatosis (n=1,2%), and neuralgic amyotrophy (n=1, 2%). Overall diagnostic accuracy of ultrasound for brachial plexus pathology was 98% (140/143), with three discordant cases (neuralgic amyotrophy n=1, inflammatory neuropathy n=1, postradiation fibrosis n=1) regarded as normal on ultrasound assessment. Sensitivity, specificity, and positive and negative predictive value of ultrasound for identifying brachial plexus pathology were 94%, 100%, 100%, and 97%, respectively.

CONCLUSION

Ultrasound identifies brachial plexus pathology with high accuracy and specificity, showing comparable diagnostic efficacy to MRI. Ultrasound can serve as an effective first-line imaging investigation for suspected brachial plexus pathology.

Brachial plexopathy as a result of anatomical prone position in COVID-19 patients-Systematic review

In patients with COVID-19 different methods improving therapy have been used, including one of the anatomical position-prone position, to support ventilation. The aim of this review was to summarize the cases of brachial plexopathy as a consequence of the prone position in COVID-19 patients, and thus bring closer the issue of the brachial plexus in the face of clinical aspects of its function, palsy, and consequences. The Preferred Reporting Items for Systematic Reviews and Meta-analyses statement was followed, inclusion criteria were created according to Patients, Interventions, Comparisons, Outcomes (PICO). PubMed and Scopus were searched until April 1, 2023 by entering the key term with Boolean terms. The risk of bias was assessed using JBI's critical appraisal tools. Fifteen papers with 30 patients were included in the review. This study showed that brachial plexopathy after the prone position occurs more often among males, who are at least 50 years old with comorbidities like hypertension, overweight, and diabetes mellitus. The most common symptoms were weakness, pain, and motion deficits. Duration of the prone position session and the number of episodes were different as well as the modification of positioning. Brachial plexopathy is a significant problem during prone position, especially when hospitalization is prolonged, patients are males, have comorbidities, and changes in body weight. Attention should be drawn to understand the anatomy of the brachial plexus, correct positioning, avoiding factors worsening the prognosis, and proper nutrition of the patients.

A Case Report on Brachial Plexus Anomaly, Embryological Basis, and Clinical Implications

This study presents the routine prosection findings of a 74-year-old male anatomical donor, whose cause of death was attributed to anoxic brain injury secondary to cardiac arrest and acute exacerbation of chronic obstructive pulmonary disease (COPD). The patient exhibited a significant medical history, including severe COPD, chronic heart failure, atrial fibrillation, hypertension, stage III chronic kidney disease, heavy alcohol abuse, obesity, coronary artery disease, peripheral edema, triple bypass surgery, and right hip replacement. A detailed examination of the upper extremities revealed anomalies within the brachial plexus, with a more pronounced presence on the left side. This particular donor deviates from the expected "typical" brachial plexus anatomy, with a lack of convergence into a lateral cord and an anomalous convergence into a superior trunk. To ensure optimal patient care and procedural outcomes, a collaborative approach between surgeons and anesthesiologists that is grounded in a comprehensive understanding of these anatomical nuances is essential. Therefore, this study aims to comprehensively investigate the identified brachial plexus anomalies, elucidate their embryological origins, and explore their clinical implications. Through these objectives, this research contributes to a broader understanding of anatomical variations and their relevance in medical practice.

Superior Trunk Block Is an Effective Phrenic-Sparing Alternative to Interscalene Block for Shoulder Arthroscopy: A Systematic Review and Meta-Analysis

The interscalene block (ISB) is the standard regional anesthesia for shoulder arthroscopy. However, the superior trunk block (STB) is an alternative with a potentially safer profile. This meta-analysis aimed to compare the incidence and degree of hemidiaphragmatic paralysis and block efficacy of these techniques. We searched MEDLINE, EMBASE, Scopus, and Cochrane databases to identify randomized controlled trials (RCTs). The main outcome was total hemidiaphragmatic paralysis. We used the Grading of Recommendation, Assessment, Development, and Evaluation (GRADE) framework to assess the certainty of evidence. Four RCTs and 359 patients were included. The STB group showed lower total hemidiaphragmatic paralysis (RR 0.07; 95% CI 0.04 to 0.14; p<0.0001). The incidence of subjective dyspnea (p = 0.002) and Horner's syndrome (p<0.001) was significantly lower with STB relative to ISB. There was no significant difference between groups in block duration (p = 0.67). There was a high certainty of evidence in the main outcome as per the GRADE framework. Our findings suggest that STB has a better safety profile than ISB, resulting in lower rates of hemidiaphragmatic paralysis and dyspnea while providing a similar block. Therefore, STB could be preferred to ISB, especially in patients susceptible to phrenic nerve paralysis complications.

Effects of the costoclavicular block versus interscalene block in patients undergoing arthroscopic shoulder surgery under monitored anesthesia care: a randomized, prospective, non-inferiority study

BACKGROUND

Recent studies have reported that costoclavicular blocks (CCBs) can consistently block almost all branches of the brachial plexus while sparing the phrenic nerve and provide effective analgesia after shoulder surgery. We aimed to compare the efficacy of the CCB with that of the interscalene block (ISB) as the sole blocking technique for shoulder surgery.

METHODS

A total of 212 patients undergoing elective arthroscopic shoulder surgery were randomized to receive an ISB or CCB based on a non-inferiority design. All patients received titration sedation with propofol under monitored anesthesia during surgery. The primary outcomes were the proportion of patients with complete motor blockade of the suprascapular nerve (SSN) and incidence of hemidiaphragmatic paralysis (HDP). The secondary outcomes included block-related variables, complications, and postoperative pain scores.

RESULTS

The proportion of patients with complete motor blockade of the SSN at 20 min between the CCB and ISB groups (53% vs. 66%) exceeded the predefined non-inferiority margin of -5%, but was comparable at 30 min (87% vs. 91%). The CCB resulted in a significantly lower incidence of HDP (7.55% vs. 92.45%), Horner's syndrome (0% vs. 18.87%), and dyspnea (0% vs. 10.38%) than the ISB. None of the patients experienced failed blocks or required conversion to general anesthesia. Pain scores were comparable between the groups.

CONCLUSIONS

Ultrasound-guided CCBs may be comparable to ISBs, with fewer unfavorable complications in patients with impaired lung function undergoing arthroscopic shoulder surgery.

The Aberrant Origin of the Suprascapular Artery May Hide Neural Covariants: A Cadaveric Finding

The axillary artery is the continuation of the subclavian artery. Occasionally, some of the subclavian artery's distal branches may atypically originate from the axillary artery, such as the suprascapular artery. The suprascapular artery's distal (low) origin from the axillary artery, instead of the subclavian artery, may also be characterized as an aberrant suprascapular artery. The current cadaveric report describes the coexistence of an aberrant suprascapular artery (of axillary origin), variant course, and termination with atypically formatted nerves originating from the cervical (the phrenic nerve) and the brachial (the long thoracic and the median nerves) plexus. An unusual interconnection between the phrenic and the long thoracic nerves was also described. The aberrant suprascapular artery had an atypical termination below the superior transverse scapular ligament, along with the suprascapular vein and nerve. Except for the atypically formatted phrenic and long thoracic nerves, the aberrant suprascapular artery coexisted with an atypical passage of the anterior ramus of the C6 spinal nerve, through the middle scalene muscle, before the long thoracic nerve formation, and a variant formation of the median nerve. Understanding neurovascular variants is crucial for interventionists and surgeons who work in the supra- and infraclavicular areas. Being aware of the different origins of the brachial plexus branches, in the supraclavicular part, may help reduce the occurrence of iatrogenic axillary injury. Efforts should be made to expand the number of cadaveric studies that investigate the origin, course, interconnection, and branching patterns of these nerves and related covariants, in a systematic way, thus unifying their study and comprehension.

Comparison of the anesthesia effect of ultrasound-guided middle and low interscalene brachial plexus block: a randomized, controlled, non-inferiority trial

BACKGROUND

Ultrasound-guided low interscalene brachial plexus block (LISB) can provide satisfactory anesthesia for surgery at or below the elbow. However, the anesthesia effect of ultrasound-guided middle interscalene brachial plexus block (MISB) has not been fully investigated. We hypothesized that MISB provides a non-inferior anesthesia effect to LISB for surgery at or below the elbow.

METHODS

A total of 82 patients with ASA I-III (18-65 years) scheduled for elective surgery at or below the elbow were randomized to the MISB group or the LISB group equally, located 1/2 or 2/3 of the caudal distance from C6 to the clavicle. Both groups were administered 15 mL 0.5% ropivacaine at the lower part of the brachial plexus with the first injection and equivalent volume at the upper part with the second injection.

RESULTS

For the primary outcome, 92.3% in the MISB group experienced successful anesthesia compared to 94.6% in the LISB group [difference: -2.3%, 95% confidence interval (CI) -13.4% to 8.8%], exceeding the predefined non-inferiority margin -15%. For the secondary outcomes, the incidence of pleura suppression for the first injection (7.7% vs. 45.9%, P < 0.001) and the time to perform the block (9.9 ± 1.3 vs. 10.7 ± 1.3 min, P = 0.006) were significantly less in MISB compared to LISB. No significant differences were observed in the consumption of perioperative rescue analgesics, VAS score, and adverse events within the two groups.

CONCLUSIONS

MISB provides a non-inferior anesthesia effect to LISB for surgery at or below the elbow.

TRIAL REGISTRATION

Chinese Clinical Trial Register (identifier: ChiCTR2100054196).

Ultrasound-guided selective peripheral nerve block compared with the sub-dissociative dose of ketamine for analgesia in patients with extremity injuries

STUDY OBJECTIVE

To compare the analgesic efficacy of ultrasound-guided selective peripheral nerve block (PNB) and sub-dissociative dose ketamine (SDK) for management of acute pain in patients with extremity injuries presenting to the emergency department (ED).

METHODS

This prospective, open-label randomized clinical trial was conducted in the ED of a tertiary care Institute. The patients were provided with either ultrasound-guided selective PNB or SDK. The primary outcome was a reduction in pain in numerical rating scale (NRS) by at least 3 points without rescue analgesia. The secondary outcomes were the need for rescue analgesia, adverse events, and patient satisfaction on either arm.

RESULTS

A total of 111 patients with isolated traumatic extremity injuries were included in the final analysis. The NRS score was significantly lower in the PNB group compared to the SDK group at 30, 60,120, 180-, and 240-min post-intervention [group ∼ time interaction, F (5, 647) = 21.53, p ≤ 0.001]. All the patients in the PNB group exhibited primary outcome (NRS ≥3 reductions) at 30 min post-intervention compared with 36 (65%) in the SDK group [-1.02(-1.422,0.622)]. Rescue analgesia was required in 10 (18%) patients in the SDK group compared to none in the PNB group [0.663(0.277,1.050)]. The decrease in NRS score from baseline at 30 min was significantly higher in PNB groups compared to the SDK group [-2.166(-2.640, -1.692)]. The most common side effect reported in the SDK group was dizziness 35(64%), followed by nausea 15(27%). None of the patients in the PNB group reported any complications. Patient satisfaction was higher in the PNB group than SDK group.

CONCLUSION

The study provides evidence that ultrasound-guided PNB is superior to SDK in terms of its analgesic efficacy in the management of acute pain due to extremity injuries and is associated with higher patient satisfaction. The need for rescue analgesia was significantly less in the PNB group. SDK was associated with a high incidence of dizziness and nausea.

The Effects of Vasodilation Induced by Brachial Plexus Block on the Development of Postoperative Thrombosis of the Arteriovenous Access in Patients with End-Stage Renal Disease: A Retrospective Study

Although brachial plexus block (BPB)-induced vasodilation reduces the incidence of arteriovenous access (AC) thrombosis, BPB cannot completely prevent its development. Therefore, we retrospectively investigated the factors affecting BPB-induced vasodilation and their effects on AC thrombosis development. Ninety-five patients undergoing AC surgery under BPB were analyzed. Vessel diameters were measured before and 20 min after BPB. The surgery abandoned before the BPB placement was performed when the BPB-induced increases in vessel diameters met its indications. Complete occlusive access thrombosis (COAT) was defined as loss of pulse, thrill, or bruit. Fourteen patients (14.7%) developed COAT. The outflow vein was more dilated by BPB than the inflow artery (0.6 versus 0.1 mm in median, p < 0.001). The original surgery plan was changed for seven patients (7.4%). Diabetes mellitus (DM) and ischemic heart disease (IHD) decreased the extent of increases in the inflow artery by -0.183 mm (95% confidence interval [CI] [-0.301, -0.065], p = 0.003) and outflow vein diameters by -0.402 mm (95% CI [-0.781, -0.024], p = 0.038), respectively. However, DM, IHD, and changes in the vessel diameters had insignificant effects on the development of COAT. In conclusion, although DM and IHD attenuate the vasodilating effects of BPB, they do not contribute to the development of COAT.

Understanding fascial anatomy and interfascial communication: implications in regional anesthesia

With the extensive application of ultrasound in regional anesthesia, there has been rapid development of interfascial plane block techniques recently. Compared with neuraxial anesthesia or nerve plexus blocks, the interfascial plane blocks have many advantages, such as technical simplicity, fewer complications and comparable or better analgesia. The concept of fascial interconnectivity is fundamental in understanding the effects and complications of interfascial plane blocks. Many fascial planes are continuous and communicate with each other without a clear anatomical boundary. The prevertebral fascia of the neck, endothoracic fascia of the chest, transversalis fascia of the abdomen, and the fascia iliaca of the pelvic cavity form a natural fascial continuation. This anatomical feature suggests that the space beneath the cervical prevertebral fascia, the thoracic paravertebral space, the space between transversalis fascia and psoas muscles (psoas major and quadratus lumborum), and the fascia iliaca compartment are a confluent potential cavity. Additionally, the permeability of the fascia at different anatomical locations to local anesthetics is different, which can also influence the block effect and the incidence of complications. This article summarizes the anatomical characteristics and communication relationships of the major fascia which are related to regional anesthesia, and their relationships with block effects and complications.

Unexpected Anatomical Variation While Performing an Ultrasound-Guided Interscalene Block for Shoulder Surgery

Anatomical variations of the brachial plexus are very common. Knowledge of the possible anatomical variations encountered in ultrasound imaging is crucial for the safe and effective practice of regional anesthesia. The interscalene block (ISB) targets the brachial plexus roots in the interscalene groove, between the anterior and middle scalene muscles (MSM), at the level of the sixth cervical vertebra. Blockade of the brachial plexus roots anesthetizes the shoulder region, making the ISB one of the preferred regional anesthesia options in shoulder surgeries. Abnormalities of the muscular structures surrounding the brachial plexus roots can pose a challenge while performing an ultrasound-guided ISB. We present a case of an unanticipated anatomical variation of the anterior scalene muscle (ASM) encountered on ultrasound imaging when performing an ISB. Our patient was found to have a small redundant ASM, which necessitated an alternative scanning approach and the use of a nerve stimulator to properly identify the brachial plexus roots. Based on our findings, we recommend placing the ultrasound probe parallel to the clavicle in the supraclavicular area and scanning in a cranial direction, tracing the brachial plexus back to the roots, and then confirming the needle placement by using a traditional nerve stimulator before local anesthetic deposition.

Effect of Fentanyl as an Adjuvant to Brachial Plexus Block for Upper Extremity Surgeries: A Systematic Review and Meta-Analysis of RCTs

Objective. To assess if the addition of fentanyl to brachial plexus block has an impact on anesthetic outcomes and complication rates in patients undergoing upper extremity surgeries. Methods. We explore the PubMed, Embase, ScienceDirect, CENTRAL, and Google Scholar databases for all randomized controlled trials (RCTs) comparing adjuvant fentanyl with placebo/no drug for patients undergoing upper extremity surgery under brachial plexus block. Outcomes assessed were onset, duration of sensory and motor anesthesia, complications, and postoperative analgesia scores. Meta-analysis was conducted utilizing a random-effects model. The risk of bias was assessed using the Cochrane Collaboration’s risk of bias assessment tool 2. Certainty of evidence was assessed using GRADE. Subgroup analysis was conducted depending upon the approach of brachial plexus block and type of local anesthetic. Results. Twelve RCTs with 660 patients were included. Addition of fentanyl had no effect on onset of sensory anesthesia (11 studies; MD: 0.48; 95% CI: −1.81, 0.85; I2 = 96%; $p=0.48$ ) but significantly shortened onset of motor anesthesia (8 studies; MD: −2.36; 95% CI: −3.99, −0.74; I2 = 96%; $p=0.48$ ). Duration of sensory anesthesia (9 studies; MD: 82.81; 95% CI: 41.81, 123.81; I2 = 99%; $p<0.0001$ ) and motor anesthesia (7 studies; MD: 93.41; 95% CI: 42.35, 144.46; I2 = 99%; $p=0.0003$ ) was significantly increased with addition of fentanyl. The certainty of evidence-based on GRADE was deemed to be moderate for both onset and duration of anesthesia. The incidence of overall complications (nausea/vomiting and pruritis) was significantly higher in the fentanyl group (7 studies; OR: 2.14; 95% CI: 1.04, 4.40; I2 = 8%; $p=0.04$ ) but with low certainty of evidence. Conclusions. Adjuvant fentanyl with brachial plexus block improves the onset of motor anesthesia but not sensory anesthesia. The duration of both sensory and motor anesthesia is significantly prolonged with fentanyl by around 83–93 minutes. However, clinicians should be aware that complications such as nausea/vomiting and pruritis are increased twofold with the addition of the drug. Current evidence is limited risk of bias in the RCTs and high heterogeneity in the meta-analyses.

Is It Useful and Necessary to Add a T2 Paravertebral Block to the Regional Anesthesia During Proximal Humeral Fracture Surgery in Elderly Patients? A Prospective and Randomized Controlled Trial

Objective

This study was designed to investigate whether it is useful and necessary to add a T2 level thoracic paravertebral block (TPVB) based on brachial-cervical plexus block to avoid incomplete anesthesia in elderly patients undergoing deltopectoral approach proximal humeral fracture (PHF) surgery.

Materials and Methods

This study involved 80 patients scheduled for PHF surgery who were randomized to receive either IC block (combined interscalene brachial plexus with superficial cervical plexus block) or ICTP block (T2 TPVB supplemented with IC block). The primary outcome was the success rate of regional anesthesia. The patient who experienced incomplete block was administered with intravenous remifentanil for rescue, or conversion to general anesthesia (GA) if remifentanil was still ineffective. Secondary outcomes included requirements of rescue anesthesia, sensory block of the surgical region, the incidence of adverse reactions, and block procedure-related complications.

Results

The success rate of regional anesthesia in the ICTP group was higher compared with the IC group (77.5 vs. 52.5%, p = 0.019). Intravenous remifentanil was required in 32.5% of patients in the IC group and 17.5% in the ICTP group, respectively. Conversion to GA was performed in 15% of patients in the IC group and 5% in the ICTP group. Sensory block at the medial proximal upper arm was achieved in 85% of patients in the ICTP group, whereas 10% in the IC group (p &lt; 0.001). There was no difference between the groups with respect to the incidence of intraoperative adverse reactions. No block-related complications occurred in either group.

Conclusion

Adding a T2 TPVB is helpful to decrease, but not absolutely avoid the occurrence of incomplete regional anesthesia during PHF surgery in elderly patients. However, considering the potential risks, it is not an ideal option while a minor dose of remifentanil can provide a satisfactory rescue effect.

Clinical Trial Registration

ClinicalTrials.gov, identifier: NCT03919422.

Supraclavicular vs. Infraclavicular Brachial Plexus Nerve Blocks: Clinical, Pharmacological, and Anatomical Considerations

: Peripheral nerve blocks (PNB) have become standard of care for enhanced recovery pathways after surgery. For brachial plexus delivery of anesthesia, both supraclavicular (SC) and infraclavicular (IC) approaches have been shown to require less supplemental anesthesia, are performed more rapidly, have quicker onset time, and have lower rates of complications than other approaches (axillary, interscalene, etc.). Ultrasound-guidance is commonly utilized to improve outcomes, limit the need for deep sedation or general anesthesia, and reduce procedural complications. Given the SC and IC approaches are the most common approaches for brachial plexus blocks, the differences between the two have been critically evaluated in the present manuscript. Various studies have demonstrated slight favorability towards the IC approach from the standpoint of complications and safety. Two prospective RCTs found a higher incidence of complications in the SC approach – particularly Horner syndrome. The IC method appears to support a greater block distribution as well. Overall, both SC and IC brachial plexus nerve block approaches are the most effective and safe approaches, particularly under ultrasound-guidance. Given the success of the supraclavicular and infraclavicular blocks, these techniques are an important skill set for the anesthesiologist for intraoperative anesthesia and postoperative analgesia.

A meta-analysis on the anatomical variability of the brachial plexus: Part II - Branching of the supraclavicular part

INTRODUCTION

The anatomy of the supraclavicular part of the brachial plexus is highly variable, therefore the aim of this study was to perform a systematic review and meta-analysis of the various origins of the long thoracic, dorsal scapular, suprascapular and subclavian nerves.

MATERIALS AND METHODS

Major electronic databases were searched to identify all cadaveric studies investigating the morphology of the supraclavicular part of the brachial plexus. Data on the origins of these nerves were extracted and classified. A random effects meta-analysis was performed to state the pooled prevalence estimates.

RESULTS

A total of 26 studies, constituting a total of 1021 cases, were deemed eligible for inclusion into the meta-analysis. The usual origin of the long thoracic nerve from the C5, C6 and C7 roots was observed in 78.1% (95% CI 69.4-86.7%) of cases and 21.9% (95% CI 13.3-30.6%) had unusual origins. An accessory long thoracic nerve occurred in 0.3% (95% CI 0-0.7%) of cases. The overall prevalence of the dorsal scapular nerve arising from its usual origin the C5 root was found in 85.2% (95% CI 75.7-94.6%) of cases, while 14.8% (95% CI 5.4-24.3%) appeared abnormal. The suprascapular nerve emerged from its usual point on the superior trunk in 89.8% (95% CI 85.1-94.4%) of cases and in 10.2% (95% CI 5.6-14.9%) of cases had a variable origin. An accessory suprascapular nerve was present in 0.2% (95% CI 0-0.6%). Two possible sites of origin of the subclavian nerve were noted and the typical origin from the superior trunk was found in 98.3% (95% CI 96.3-100%) of cases and variable origin from the C5 root in 1.7% (95% CI 0-3.7%). All unusual origins of each nerve were much less common.

CONCLUSIONS

The nerves emerging from the supraclavicular part of the brachial plexus express a wide spectrum of potential origins. Based on their various origins, a new classification system for all the nerves belonging to the supraclavicular part was proposed. Knowledge of these variations and their prevalence data is important to prevent iatrogenic injuries and to state useful landmarks for interventions in the axilla.

A randomised, non-inferiority study of chloroprocaine 2% and ropivacaine 0.75% in ultrasound-guided axillary block

Chloroprocaine is a short-acting local anaesthetic with a rapid onset of action and an anaesthesia duration up to 60 min. In this pivotal study success rates, onset and remission of motor and sensory block and safety of chloroprocaine 2% was compared to ropivacaine 0.75% for short-duration distal upper limb surgery with successful block rates as primary outcome. The study was designed as a prospective, randomised, multi-centre, active-controlled, double-blind, parallel-group, non-inferiority study, performed in 4 European hospitals with 211 patients scheduled for short duration distal upper limb surgery under axillary plexus block anaesthesia. Patients received either ultrasound guided axillary block with 20 ml chloroprocaine 2%, or with 20 ml ropivacaine 0.75%. Successful block was defined as block without any supplementation in the first 45 min calculated from the time of readiness for surgery. 90.8% patients achieved a successful block with chloroprocaine 2% and 92.9% patients with Ropivacaine 0.75%, thus non-inferiority was demonstrated (10% non inferiority margin; 95% CI − 0.097, 0.039; p = 0.02). Time to onset of block was not significantly different between the groups. Median time to motor and sensory block regression was significantly shorter as was time to home discharge (164 [155–170] min for chloroprocaine versus 380 [209–450] for the ropivacaine group, p < 0.001). For short-duration surgical procedures, the short-acting Chloroprocaine 2% may be used, with success rates non-inferior to ropivacaine and a favourable safety profile.

Trial registration: The trial was registered at Clinicaltrials.gov with registration number NCT02385097 (March 11th, 2015) and European Clinical Trial Database with the EudraCT number 2014-002519-40 (July 7th, 2015, Austria—BASG).

The effect of wide-awake anesthesia, intravenous regional anesthesia, and infraclavicular brachial plexus block on cost and clinical scores of patients undergoing hand surgery

The aim of our study was to compare the clinical results and costs of wide-awake local anesthesia no tourniquet (WALANT), intravenous regional anesthesia (IVRA), and infraclavicular brachial plexus block (IC-BPB). The patients were divided into WALANT, IVRA, IC-BPB groups, each with 50 patients. Demographic information, induction time, use of sedation, number of patients who were converted to general anesthesia, time in postanesthesia care unit (PACU), amount of bleeding during surgery, presence of tourniquet pain, hand motor function during surgery, time to onset of postanesthesia pain, discharge time, complications, and anesthesia costs were compared. Sedation was given to 12 IC-BPB patients, 9 IVRA patients and 5 WALANT patients. Of these patients, 6 undergoing IC-BPB, 5 undergoing IVRA and 4 undergoing WALANT were converted to general anesthesia (p = 0.80). PACU time and anesthesia costs were the least in the WALANT group, followed by the IVRA group (p < 0.001, p < 0.001). Intraoperative active voluntary movements were best preserved in the WALANT group; however, bleeding was highest in the WALANT group (p < 0.001, p < 0.001). Tourniquet pain was the higher in the IVRA groups, while postoperative pain in the surgical area developed the fastest in this same group (p = 0.029, p < 0.001). Time to discharge was similar in WALANT and IVRA groups, and the longest in the IC-BPB (p < 0.001) group. There was no difference among the groups in terms of patient satisfaction (p = 0.085, p = 0.242 for the first and second survey question). In the current study, WALANT appears to be a suitable alternative to IVRA and IC-BPB methods, with better preservation of active intraoperative movement, lower cost, and shorter time spent in PACU at the expense of higher bleeding.

Patient satisfaction with intravenous regional anaesthesia or an axillary block for minor ambulatory hand surgery: A randomised controlled study

BACKGROUND

Intravenous regional anesthesia (IVRA) and the axillary brachial plexus block are popular alternatives to general anaesthesia in ambulatory hand surgery. Although both have proven their effectiveness, patients' preferences have never been evaluated.

OBJECTIVES

We investigated patient satisfaction with both techniques and hypothesised that satisfaction after IVRA is noninferior compared with axillary brachial plexus block.

DESIGN

A prospective, randomised controlled trial.

SETTING

Ambulatory surgical day care centre, University Hospitals of Leuven, Belgium, from September 2016 to November 2017.

PATIENTS

One hundred and twenty adults undergoing minor ambulatory hand surgery were included in this study.

INTERVENTION

Patients received either IVRA with 300 mg lidocaine or an axillary block with 280 mg mepivacaine.

MAIN OUTCOME MEASURES

The primary endpoint was the evaluation of patient satisfaction using the 'Evaluation du Vécu de l'Anésthesie Locoregional' (EVAN-LR) questionnaire. Secondary outcomes included different procedural times, block quality, tourniquet discomfort, the incidence of block failure and postoperative nausea and vomiting (PONV), the severity of postoperative pain and the need for postoperative analgesics during the first 24 h.

RESULTS

Noninferiority of IVRA was shown for the median [IQR] total score on the EVAN-LR questionnaire, IVRA-group: 92 [87 to 96] vs. axillary brachial plexus block-group: 91[87 to 97]; Hodges--Lehmann estimator (95% confidence interval (CI)] for the shift: -0.25 (-2.60 to 2.20). Induction of anaesthesia and time to discharge, requiring partial recovery of the motor block, were significantly longer in the axillary brachial plexus block group. The IVRA-group had a lower block quality, a higher incidence of tourniquet-discomfort and higher median intra-operative and postoperative pain scores on day 0; 0 [0 to 2] vs. 0 [0 to 0] and 0.8 [0 to 1.8] vs. 0 [0 to 0.25], respectively, but no increase in the need for supplementary analgesics or conversion rate to general anaesthesia.

CONCLUSION

IVRA and axillary brachial plexus block result in comparably high patient satisfaction in ambulatory hand surgery.

CLINICAL TRIAL REGISTRATION

EudraCT 2016-002325-11.

A comparison of ice wrap and subacromial injection for postoperative pain and edema control following arthroscopic rotator cuff repair

Background

Postoperative pain and edema are the most common problems associated with arthroscopic rotator cuff repair. The purpose of the present study was to compare ice wrap and subacromial injection (SI) as treatments for early postop pain and edema control and to contrast them with a control group.

Materials and methods

59 patients treated with arthroscopic rotator cuff repair were randomized into three groups: 23 patients who received an ice wrap, 20 patients who received a SI, and a control group of 16 patients.

Results

Patient demographics, comorbidities, tear retraction, degree of fatty muscle degeneration, surgical procedures, and amount of irrigation fluid were similar for the three groups, which also showed similar results regarding postoperative pain and edema control as well as analgesic consumption.

Conclusions

The present study failed to show any difference in effectiveness between the two most common pain management modalities, or between those modalities and the control group.

Level of evidence

IV, prospective observational study.

Onset times and duration of analgesic effect of various concentrations of local anesthetic solutions in standardized volume used for brachial plexus blocks

Visualization of the nerve structures of brachial plexus allows anesthesiologists to use a lower dose of local anesthetics. The content of this low dose is not unequivocal, consequently, the pharmacokinetics of local anesthetics used by various authors are difficult to compare. In this study, the onset times and duration of the analgesic effect of local anesthetic mixture solutions used for brachial plexus blocks are investigated and the quality of anesthesia is compared. 85 unpremedicated American Society of Anesthesiologist physical status I-III, 19-83-year-old patients scheduled for upper limb trauma surgery are assigned to four groups for the axillary-supraclavicular block with lidocaine 1% and bupivacaine 0,5% 1:1 mixture (Group LB) or bupivacaine 0.33% (Group BS) or lidocaine 0,66% (Group LS) or bupivacaine 0.5% and lidocaine 1% 2:1 mixture (Group BL). 0.4 ml/kg was administered to the four groups. The onset time was significantly shorter in the lidocaine group (LS 13.0 ± 1.02) than in the other study groups (LB 16.64 ± 0.89; BS 17.21 ± 0.74; BL 16.92 ± 0.51 min ±SEM, p = 0.002). No differences were observed in the onset times between LB, BS, and BL groups (p > 0.05). Statistical differences were found in the duration of local anesthetics between LB (392.9 ± 20.4), BS (546.4 ± 14.9), LS (172.85 ± 7.8), and BL (458.7 ± 11.9 min ±SEM, p = 0.001). Lidocaine does not shorten the onset times, but significantly decreases the duration of action of bupivacaine when used in mixture solutions. Lidocaine exhibits a good quality of block in the applied dose, while other solutions have excellent quality. Bupivacaine without lidocaine has the longest duration of action to achieve the longest postoperative analgesia.

Neurovascular axillary variations: superficial brachial artery and single-corded brachial plexus

Variants of the axillary artery and brachial plexus were found bilaterally in the axilla of an 86-year-old Asian female. On the left, the cadaver donor had a high bifurcation of the second part of the axillary artery, creating a superficial brachial artery. Meanwhile, the right axilla presented with root, trunk, and cord variations in the formation of the brachial plexus, the most interesting feature being a single, unified cord. Presented in this case report are the structural relationships of the variants with considerations regarding anatomy, embryology, prevalence, and clinical importance.

Integrating a Cadaver Review Session into the Existing Regional Anesthesia Training for Anesthesiology Residents: An Initial Experience

The Department of Anesthesiology's Acute Pain Service (APS) places ultrasound-guided peripheral nerve blocks (PNBs) to manage acute peri-operative pain. PNB success is dependent on detailed anatomical knowledge which residents may not have formally reviewed since medical school. This study describes the integration of a cadaver review session (CRS) that reintroduces PNB-related anatomy into the existing APS rotation. During each CRS, an anatomist reviewed the major nerve and surrounding structures, while an APS attending integrated the anatomy with PNB techniques. During the pilot, 1st- and 3rd-year clinical anesthesia (CA) residents (9 CA1s, 7 CA3s) completed pre- and post-session surveys and rated the CRS's perceived value and impact on self-confidence with anatomical knowledge. Following the pilot, an additional 17 CA1s and 9 CA3s participated in the CRS and completed post-session surveys. Descriptive statistics were used to summarize responses and unpaired t tests were used to compare pre- and post-session responses and responses between cohorts. All participants were overwhelmingly positive about the CRS and its value to the APS rotation, with 98% agreeing they recommend the CRS and found it accessible. Residents believed participation would improve board exam (average = 4.83 ± 0.66) and clinical performance (average = 4.86 ± 0.65), and self-reported increases in confidence with anatomical knowledge. Residents in the pilot group reported significantly greater confidence (p < 0.01) in their perceived anatomical knowledge after the CRS. The CRS positively impacted resident confidence in their anatomical knowledge and perceived ability to identify anatomical structures. Residents reported the CRS was a highly valued addition to regional anesthesia training.

The brachial plexus - explaining its morphology and variability by a generic developmental model

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.

Effects of regional anesthesia techniques on local anesthetic plasma levels and complications in carotid surgery: a randomized controlled pilot trial

BACKGROUND

The ultrasound guided intermediate cervical plexus block with perivascular infiltration of the internal carotid artery (PVB) is a new technique for regional anesthesia in carotid endarterectomy (CEA). We conducted a pilot study investigating the effects of deep cervical block (DCB), intermediate cervical block alone (ICB) and PVB on perioperative complications in patients undergoing elective CEA. We hypothesized, that the ropivacaine plasma concentration is higher in patients receiving DCB compared to PVB and ICB.

METHODS

In a randomized controlled pilot study thirty patients scheduled for elective CEA were randomly assigned into three groups: DCB receiving 20 mL ropivacaine 0.5% (n = 10), ICB receiving 20 mL ropivacaine 0.5% (n = 10) and PVB receiving 20 mL ropivacaine 0.5% and 10 mL ropivacaine 0,3% (n = 10). As primary outcome, plasma levels of ropivacaine were measured with high performance liquid chromatography before, 5, 10, 20, 60, and 180 min after the injection of ropivacaine. Secondary outcomes were vascular and neurological complications as well as patients' and surgeons' satisfaction. All analyses were performed on an intention-to-treat basis. Statistical significance was accepted at p < 0.05.

RESULTS

No conversion to general anesthesia was necessary and we observed no signs of local anesthetic intoxication or accidental vascular puncture. Plasma concentration of ropivacaine was significantly higher in the DCB group compared to PVB and ICB (p < 0.001) and in the PVB group compared to ICB (p = 0.008). Surgeons' satisfaction was higher in the PVB group compared to ICB (p = 0.003) and patients' satisfaction was higher in the PVB group compared to ICB (p = 0.010) and DCB group (p = 0.029). Phrenic nerve paralysis was observed frequently in the DCB group (p < 0.05). None of these patients with hemi-diaphragmatic paralysis showed signs of respiratory distress.

CONCLUSION

The ultrasound guided PVB is a safe and effective technique for CEA which is associated with lower plasma levels of local anesthetic than the standard DCB. Considering the low rate of complications in all types of regional anesthesia for CEA, larger randomized controlled trials are warranted to assess potential side effects among the blocks.

TRIAL REGISTRATION

The trial was registered at German Clinical Trials Register (DRKS) on 04/05/2019 (DRKS00016705, retrospectively registered).

Interscalene brachial plexus nerve block in the emergency department: an effective and practice-changing workshop

Background

The interscalene brachial plexus nerve block (ISNB) is a potentially useful method of regional analgesia for humerus fracture and shoulder dislocation reduction in the Emergency Department (ED). We examined the effectiveness of an ISNB workshop given to emergency medicine (EM) residents. We also explored complication rates and effectiveness of ISNBs performed in the ED.

Methods

One-hour evidence-based ISNB workshops were conducted with EM residents. Participants were given pre-, post-, and 3-month post-workshop knowledge and technical assessments. Results were analyzed using descriptive statistics. A pre- and post-workshop chart review examined ISNB utilization, complications, post-ISNB opiate administration, and post-ISNB procedural sedation.

Results

41 residents enrolled in the workshop. Pre-workshop pass rate: knowledge assessment 22%. Immediate post-workshop pass rates: knowledge assessment 100%, image acquisition 93%, needle placement 100%. Three months post-workshop pass rates: knowledge assessment 73%, image acquisition 76%, needle placement 100%. Areas of poorest knowledge retention were anatomical landmarks, block distribution, and early signs of LAST. In the chart review, 2 ISNBs were performed in the pre-workshop period, and 12 in the post-workshop period. No serious complications were recorded. 78.5% of attempted ISNBs were successful, without need for procedural sedation. Of the 11 successfully performed ISNBs, 91% received no opiates after the procedure.

Conclusions

Our study suggests that EM residents can learn the ISNB, perform it safely in the emergency department, and that the ISNB may be an alternative to procedural sedation and opiate use for shoulder dislocation. Residents are adept at ISNB technical skills but demonstrate some deficits in knowledge retention.

Total Spinal Anesthesia Following an Interscalene Block Treated with Intravenous Lipid Emulsion

Total spinal anesthesia following interscalene block is a rare and life-threatening complication of regional anesthesia. A 56-year-old woman underwent an uncomplicated left shoulder bone spur removal under general anesthesia with an interscalene nerve block at an outpatient surgical center. Subsequently, she developed bilateral mydriasis, paralysis of all extremities, and respiratory arrest. She was intubated and transferred to the emergency department (ED) where she was given intravenous lipid emulsion (ILE) with complete recovery of neurological function. ILE therapy may be considered as a rescue treatment in addition to supportive therapy for total spinal anesthesia.

Phantom Sensations Following Brachial Plexus Nerve Block: A Case Report

Following the administration of brachial plexus anesthesia for right thumb carpometacarpal arthroplasty with ligament reconstruction, a 54-year-old woman with all limbs intact developed phantom limb sensations, including the misperception of the placement of her right arm and frozen limb sensations in her fingers. Immobility of her fingers in a stacked position was experienced for ~3.5 days after surgery, and she described her phantom sensations as the hand experiencing "tingling" and feeling "heavy." While the onset of these phantom sensations occurred almost immediately after administration of brachial plexus anesthesia, they lasted for ~69 h after anesthesia wear off, suggesting that cortical effects from denervation resolves much more slowly than initial remapping, giving insight into the mechanisms behind phantom limb sensations that are often experienced by amputees.

Intraoperative monitoring of neuromuscular function with soft, skin-mounted wireless devices

Peripheral nerves are often vulnerable to damage during surgeries, with risks of significant pain, loss of motor function, and reduced quality of life for the patient. Intraoperative methods for monitoring nerve activity are effective, but conventional systems rely on bench-top data acquisition tools with hard–wired connections to electrode leads that must be placed percutaneously inside target muscle tissue. These approaches are time and skill intensive and therefore costly to an extent that precludes their use in many important scenarios. Here we report a soft, skin-mounted monitoring system that measures, stores, and wirelessly transmits electrical signals and physical movement associated with muscle activity, continuously and in real-time during neurosurgical procedures on the peripheral, spinal, and cranial nerves. Surface electromyography and motion measurements can be performed non-invasively in this manner on nearly any muscle location, thereby offering many important advantages in usability and cost, with signal fidelity that matches that of the current clinical standard of care for decision making. These results could significantly improve accessibility of intraoperative monitoring across a broad range of neurosurgical procedures, with associated enhancements in patient outcomes.

A small skin-mounted biosensing device accurately and non-invasively monitors neuromuscular activity in real-time during surgery. With many surgical procedures there is a risk of nerve damage. Although this is often temporary, in some cases it can significantly affect patients’ quality of life. Existing monitoring systems that rely on the accurate placement of needle electrodes into target nerves are cumbersome and expensive. The device developed by a team led by John Rogers, at Northwestern University, and Michel Kliot, at Stanford University, can easily be accommodated to any part of the body to monitor muscle activity in response to nerve impulses and stimulation during surgery. Furthermore, it can wirelessly transmit signals of comparable quality to needle-based systems. These devices could not only increase the use of intraoperative monitoring in hospitals but also contribute to make surgery safer.

Transition from Deep Regional Blocks toward Deep Nerve Hydrodissection in the Upper Body and Torso: Method Description and Results from a Retrospective Chart Review of the Analgesic Effect of 5% Dextrose Water as the Primary Hydrodissection Injectate to Enhance Safety

Deep nerve hydrodissection uses fluid injection under pressure to purposely separate nerves from areas of suspected fascial compression, which are increasingly viewed as potential perpetuating factors in recalcitrant neuropathic pain/complex regional pain. The usage of 5% dextrose water (D5W) as a primary injectate for hydrodissection, with or without low dose anesthetic, could limit anesthetic-related toxicity. An analgesic effect of 5% dextrose water (D5W) upon perineural injection in patients with chronic neuropathic pain has recently been described. Here we describe ultrasound-guided methods for hydrodissection of deep nerve structures in the upper torso, including the stellate ganglion, brachial plexus, cervical nerve roots, and paravertebral spaces. We retrospectively reviewed the outcomes of 100 hydrodissection treatments in 26 consecutive cases with a neuropathic pain duration of 16 ± 12.2 months and the mean Numeric Pain Rating Scale (NPRS) 0-10 pain level of 8.3 ± 1.3. The mean percentage of analgesia during each treatment session involving D5W injection without anesthetic was 88.1%  ±  9.8%. The pretreatment Numeric Pain Rating Scale score of 8.3 ± 1.3 improved to 1.9 ± 0.9 at 2 months after the last treatment. Patients received 3.8 ± 2.6 treatments over 9.7 ± 7.8 months from the first treatment to the 2-month posttreatment follow-up. Pain improvement exceeded 50% in all cases and 75% in half. Our results confirm the analgesic effect of D5W injection and suggest that hydrodissection using D5W provides cumulative pain reduction.

Perioperative Pain Management for Upper Extremity Surgery

Upper extremity surgeons are currently faced with a daunting array of anesthesia techniques, ranging from traditional general anesthesia to wide-awake surgery, during which patients can watch their surgeons operate in the morning and return to work as soon as that afternoon. This range of options means that surgeons must consider patient-related factors such as disease process and relevant comorbidities, as well as surgery-related factors such as anatomic location, complexity, length of procedure, and postoperative pain expectations. In general, the least invasive technique is favored, but each patient must be considered individually to ensure the best anesthesia choice.

Effects of arthroscopy-guided suprascapular nerve block combined with ultrasound-guided interscalene brachial plexus block for arthroscopic rotator cuff repair: a randomized controlled trial

PURPOSE

The aim of this study was to compare the pain relieving effect of ultrasound-guided interscalene brachial plexus block (ISB) combined with arthroscopy-guided suprascapular nerve block (SSNB) with that of ultrasound-guided ISB alone within the first 48 h after arthroscopic rotator cuff repair.

METHODS

Forty-eight patients with rotator cuff tears who had undergone arthroscopic rotator cuff repair were enrolled. The 24 patients in group 1 received ultrasound-guided ISB and arthroscopy-guided SSNB; the remaining 24 patients in group 2 underwent ultrasound-guided ISB alone. Visual analogue scale pain score and patient satisfaction score were checked at 1, 3, 6, 12, 18, 24, and 48 h post-operatively.

RESULTS

Group 1 had a lower visual analogue scale pain score at 3, 6, 12, 18, 24, and 48 h post-operatively (1.7 < 2.6, 1.6 < 4.0, 3.5 < 5.8, 3.6 < 5.2, 3.2 < 4.2, 1.3 < 2.0), and a higher patient satisfaction score at 6, 12, 18, 24, and 36 h post-operatively than group 2 (7.8 > 6.0, 6.2 > 4.3, 6.4 > 5.1, 6.9 > 5.9, 7.9 > 7.1). Six patients in group 1 developed rebound pain twice, and the others in group 1 developed it once. All of the patients in group 2 had one rebound phenomenon each (p = 0.010). The mean timing of rebound pain in group 1 was later than that in group 2 (15.5 > 9.3 h, p < 0.001), and the mean size of rebound pain was smaller in group 1 than that in group 2 (2.5 > 4.0, p = 0.001).

CONCLUSION

Arthroscopy-guided SSNB combined with ultrasound-guided ISB resulted in lower visual analogue scale pain scores at 3-24 and 48 h post-operatively, and higher patient satisfaction scores at 6-36 h post-operatively with the attenuated rebound pain compared to scores in patients who received ultrasound-guided ISB alone after arthroscopic rotator cuff repair. The combined blocks may relieve post-operative pain more effectively than the single block within 48 h after arthroscopic cuff repair.

LEVEL OF EVIDENCE

Randomized controlled trial, Level I. ClinicalTrials.gov Identifier: NCT02424630.

Suprascapular block associated with supraclavicular block: An alternative to isolated interscalene block for analgesia in shoulder instability surgery?

BACKGROUND

Interscalene brachial plexus block (ISB) is the gold standard for postoperative pain management in shoulder surgery. However, this technique has side effects and potentially serious complications. The aim of this study was to compare the combinations of ultrasound-guided suprascapular (SSB) associated with supraclavicular nerve block (SCB) and ultrasound-guided ISB for postoperative analgesia after shoulder instability surgery.

METHODS

Sixty ASA physical status I-II patients scheduled to undergo shoulder instability surgery were included. Two groups: (i) the SSB+SCB group (n=30) in which the patients received a combination of US-guided SSB (15mL of bupivacaine 0.25%) and US-guided SCB (15mL of bupivacaine 0.25%) and (ii) the ISB group (n=30) in which the patients received US-guided ISB with 30mL of bupivacaine 0.25%. General anesthesia was administered to all patients. During the first 24h, the variables assessed were time to administer the anesthesia, duration of the analgesia, onset and duration of motor and sensory blockade, opioid consumption, cardiovascular stability, complications, and patient satisfaction.

RESULTS

Anesthesia induction took more time for the SSB+SCB group than for the ISB group. However, the onset time of motor and sensory blockade was similar in the two groups. Statistical analysis of the visual analog postoperative pain scoring at H0, H6, H12, and H24 showed nonsignificant differences between the groups. Analgesia, the first request for morphine, and total morphine consumption during the first 24h was similar in both groups. No complication was recorded in the SSB+SCB group. However, phrenic nerve block occurred in all patients in the ISB group.

CONCLUSION

US-guided SCB combined with US-guided SSB was as effective as ISB for postoperative analgesia after shoulder instability surgery without decreasing potential side effects.

TRIAL REGISTRATION

NCT identifier: NCT02397330.

Risk of Encountering Dorsal Scapular and Long Thoracic Nerves during Ultrasound-guided Interscalene Brachial Plexus Block with Nerve Stimulator

BACKGROUND

Recently, ultrasound has been commonly used. Ultrasound-guided interscalene brachial plexus block (IBPB) by posterior approach is more commonly used because anterior approach has been reported to have the risk of phrenic nerve injury. However, posterior approach also has the risk of causing nerve injury because there are risks of encountering dorsal scapular nerve (DSN) and long thoracic nerve (LTN). Therefore, the aim of this study was to evaluate the risk of encountering DSN and LTN during ultrasound-guided IBPB by posterior approach.

METHODS

A total of 70 patients who were scheduled for shoulder surgery were enrolled in this study. After deciding insertion site with ultrasound, awake ultrasound-guided IBPB with nerve stimulator by posterior approach was performed. Incidence of muscle twitches (rhomboids, levator scapulae, and serratus anterior muscles) and current intensity immediately before muscle twitches disappeared were recorded.

RESULTS

Of the total 70 cases, DSN was encountered in 44 cases (62.8%) and LTN was encountered in 15 cases (21.4%). Both nerves were encountered in 10 cases (14.3%). Neither was encountered in 21 cases (30.4%). The average current measured immediately before the disappearance of muscle twitches was 0.44 mA and 0.50 mA at DSN and LTN, respectively.

CONCLUSIONS

Physicians should be cautious on the risk of injury related to the anatomical structures of nerves, including DSN and LTN, during ultrasound-guided IBPB by posterior approach. Nerve stimulator could be another option for a safer intervention. Moreover, if there is a motor response, it is recommended to select another way to secure better safety.

Postoperative pain control after arthroscopic rotator cuff repair

Arthroscopic rotator cuff repair (ARCR) can provide excellent clinical results for patients who fail to respond to conservative management of symptomatic rotator cuff tears. ARCR, however, can be associated with severe postoperative pain and discomfort that requires adequate analgesia. As ARCR continues to shift toward being performed as an outpatient procedure, it is incumbent on physicians and ambulatory surgical centers to provide appropriate pain relief with minimal side effects to ensure rapid recovery and safe discharge. Although intravenous and oral opioids are the cornerstone of pain management after orthopedic procedures, they are associated with drowsiness, nausea, vomiting, and increased length of hospital stay. As health care reimbursements continue to become more intimately focused on quality, patient satisfaction, and minimizing of complications, the need for adequate pain control with minimal complications will continue to be a principal focus for providers and institutions alike. We present a review of alternative modalities for pain relief after ARCR, including cryotherapy, intralesional anesthesia, nerve blockade, indwelling continuous nerve block catheters, and multimodal anesthesia. In choosing among these modalities, physicians should consider patient- and system-based factors to allow the efficient delivery of analgesia that optimizes recovery and improves patient satisfaction.

Brachial plexus injury: treatment options and outcomes

The brachial plexus is a series of nerves formed by roots of cervical segments 5 to 8 (C5-C8) as well as the first thoracic nerve (T1). It functions to provide sensation and motor innervation to the skin and muscles of the chest and upper limb. It does so through different segments: roots, trunks, divisions, and cords. Injuries to the brachial plexus occur relatively frequently and are due mainly to traumatic accidents that lead to traction or compression of the nerve roots. When considering the etiology and treatment of such injuries, it is important to make a distinction between adult versus obstetric brachial plexus injury. Although several surgical treatment options are described and used for patients with brachial plexus injury, no perfect remedy currently exists. Prevention and safety should be the focus. At the same time, high-quality studies and new technology and techniques are needed to determine more effective treatments for this group.