Nerve blocks at the wrist for carpal tunnel release revisited: the use of sensory-nerve and motor-nerve stimulation techniques

A Comparison of Distal Nerve Blocks and Brachial Plexus Blocks in Terms of Block Success, Block-related Characteristics, Time to Discharge and Patient Satisfaction

Background: Ultrasound-guided brachial plexus blocks (BPB) are used as an anaesthetic method in hand and wrist surgeries. The radial, median and ulnar nerves can also be selectively blocked. The objective of this retrospective cohort study was to compare distal nerve blocks (DNB) and BPB in terms of block success, block-related characteristics, time to discharge and patient satisfaction. Methods: The data of patients who underwent elective hand and wrist surgery under regional anaesthetic procedures between 01.01.2022 and 01.09.2022 were analysed. Standard multimodal analgesia was performed in all groups, in addition to either ultrasound-guided BPB or DNB. Demographic characteristics, American Society of Anaesthesiology (ASA) classes, presence of additional diseases, block and volume applied, block-related data such as block performance time, onset time, initial analgesia times, perioperative additional anaesthetic or analgesic requirement, surgery times, types of surgery, discharge times and the presence of additional complaints were recorded. In addition, the anaesthesia quality score were determined using a 5-point Likert scale. Results: There was no difference between demographic data. Average surgical time was similar between the DNB and BPB groups (46.0 ± 8.92 vs. 59.95 ± 22.04 min, p < 0.05). Block onset time was significantly lower in the DNB group (26.4 ± 2.73 vs. 32.17 ± 2.94 min, p < 0.001). When patients discharged before and after 12 hours were compared, 11/22 of the patients in the DNB group and 4/23 of the patients in the BPB group were discharged in the first 12 hours (p < 0.05). Patient satisfaction scores were similar between groups (14.22 ± 0.86 vs. 13.65 ± 1.11, p > 0.05). Conclusions: In surgeries of the hand and wrist, the radial, median and ulnar nerves can be used individually or in combination as an alternative to proximal BPB. Level of Evidence: Level III (Therapeutic).

An Update on Treatment Modalities for Ulnar Nerve Entrapment: A Literature Review

CONTEXT

Ulnar nerve entrapment is a relatively common entrapment syndrome second only in prevalence to carpal tunnel syndrome. The potential anatomic locations for entrapment include the brachial plexus, cubital tunnel, and Guyon's canal. Ulnar nerve entrapment is more so prevalent in pregnancy, diabetes, rheumatoid arthritis, and patients with occupations involving periods of prolonged elbow flexion and/or wrist dorsiflexion. Cyclists are particularly at risk of Guyon's canal neuropathy. Patients typically present with sensory deficits of the palmar aspect of the fourth and fifth digits, followed by motor symptoms, including decreased pinch strength and difficulty fastening shirt buttons or opening bottles.

EVIDENCE ACQUISITION

Literature searches were performed using the below MeSH Terms using Mendeley version 1.19.4. Search fields were varied until further searches revealed no new articles. All articles were screened by title and abstract. Decision was made to include an article based on its relevance and the list of final articles was approved three of the authors. This included reading the entirety of the artice. Any question regarding the inclusion of an article was discussed by all authors until an agreement was reached.

RESULTS

X-ray and CT play a role in diagnosis when a bony injury is thought to be related to the pathogenesis (i.e., fracture of the hook of the hamate.) MRI plays a role where soft tissue is thought to be related to the pathogenesis (i.e., tumor or swelling.) Electromyography and nerve conduction also play a role in diagnosis. Medical management, in conjunction with physical therapy, shows limited promise. However, minimally invasive techniques, including peripheral percutaneous electrode placement and ultrasound-guided electrode placement, have all been recently studied and show great promise. When these techniques fail, clinicians should resort to decompression, which can be done endoscopically or through an open incision. Endoscopic ulnar decompression shows great promise as a surgical option with minimal incisions.

CONCLUSIONS

Clinical diagnosis of ulnar nerve entrapment can often be delayed and requires the suspicion as well as a thorough neurological exam. Early recognition and diagnois are important for early institution of treatment. A wide array of diagnostic imaging can be useful in ruling out bony, soft tissue, or vascular etiologies, respectively. However, clinicians should resort to electrodiagnostic testing when a definitive diagnois is needed. Many new minimally invasive techniques are in the literature and show great promise; however, further large scale trials are needed to validate these techniques. Surgical options remains as a gold standard when adequate symptom relief is not achieved through minimally invasive means.

Ibuprofen timing for hand surgery in ambulatory care

OBJECTIVE:

To evaluate the effect of pre-operative administration of ibuprofen on post-operative pain control vs. early post-operative administration for hand surgery procedures performed under local anaesthesia in ambulatory care.

METHODS:

Candidates to trigger finger release by De Quervain tenosynovitis and carpal tunnel operation under local anesthesia were enrolled in the study. Group A received 400 mg ibuprofen before the operation and placebo after the procedure; group B received placebo before the operation and ibuprofen 400 mg at the end of the procedure; both groups received ibuprofen 400 mg every 6h thereafter. Visual analogue scale (VAS) was measured at fixed times before and every 6h after surgery, for a total follow-up of 18h.

RESULTS:

Groups were similar according to age, gender and type of surgery. Median VAS values did not produce any statistical significance, while there was a statistically significant difference on pre-operative and early post-operative VAS values between groups (A -8.53 mm vs. B 3.36 mm, p=0.0085).

CONCLUSION:

Average pain levels were well controlled by local anesthesia and post-operative ibuprofen analgesia. Pre-operative ibuprofen administration can contribute to improve early pain management. Level of Evidence II, Therapeutic Studies.

A triple-masked, randomized controlled trial comparing ultrasound-guided brachial plexus and distal peripheral nerve block anesthesia for outpatient hand surgery

Background. For hand surgery, brachial plexus blocks provide effective anesthesia but produce undesirable numbness. We hypothesized that distal peripheral nerve blocks will better preserve motor function while providing effective anesthesia. Methods. Adult subjects who were scheduled for elective ambulatory hand surgery under regional anesthesia and sedation were recruited and randomly assigned to receive ultrasound-guided supraclavicular brachial plexus block or distal block of the ulnar and median nerves. Each subject received 15 mL of 1.5% mepivacaine at the assigned location with 15 mL of normal saline injected in the alternate block location. The primary outcome (change in baseline grip strength measured by a hydraulic dynamometer) was tested before the block and prior to discharge. Subject satisfaction data were collected the day after surgery. Results. Fourteen subjects were enrolled. Median (interquartile range [IQR]) strength loss in the distal group was 21.4% (14.3, 47.8%), while all subjects in the supraclavicular group lost 100% of their preoperative strength, P = 0.001. Subjects in the distal group reported greater satisfaction with their block procedures on the day after surgery, P = 0.012. Conclusion. Distal nerve blocks better preserve motor function without negatively affecting quality of anesthesia, leading to increased patient satisfaction, when compared to brachial plexus block.

Choice of loco-regional anesthetic technique affects operating room efficiency for carpal tunnel release

Intravenous regional anesthesia (Bier block) is indicated for minor procedures such as carpal tunnel release but must be performed in the operating room. We hypothesize that preoperative peripheral nerve blocks decrease anesthesia-controlled time compared to Bier block for carpal tunnel release. With IRB approval, we reviewed surgical case data from a tertiary care university hospital outpatient surgery center for 1 year. Unilateral carpal tunnel release cases were grouped by anesthetic technique: (1) preoperative nerve blocks, or (2) Bier block. The primary outcome was anesthesia-controlled time (minutes). Secondary outcomes included surgical time and time for nerve block performance in minutes, when applicable. Eighty-nine cases met criteria for analysis (40 nerve block and 49 Bier block). Anesthesia-controlled time [median (10th-90th percentiles)] was shorter for the nerve block group compared to Bier block [11 (6-18) vs. 13 (9-20) min, respectively; p = 0.02). Surgical time was also shorter for the nerve block group vs. the Bier block group [13 (8-21) and 17 (10-29) min, respectively; p < 0.01), but nerve blocks took 10 (5-28) min to perform. Ultrasound-guided nerve blocks performed preoperatively reduce anesthesia-controlled time compared to Bier block and may be a useful anesthetic modality in some practice environments.

An objective assessment of nerve stimulators used for peripheral nerve blockade*

Nerve stimulation is considered by many to be the current 'gold standard' for locating peripheral nerves. Thirteen nerve stimulators were subjected to a battery of tests performed by two independent observers under standardised conditions using a digital oscilloscope, a calibrated resistance and a novel scoring system. Individual scores were assigned for the signal waveform, current intensity, impulse duration, maximum load output and functionality of each nerve stimulator; the maximum score achievable was 20. A score of > or = 15/20 was achieved by six nerve stimulators: Stimuplex HNS 12 (B Braun); MultiStim Vario (Pajunk); Plexival (Medival, Vygon); MultiStim Sensor (Pajunk); Plexygon (Aryon, Vygon); Stimuplex HNS 11 (B Braun). Seven nerve stimulators scored < 15/20. Anaesthetists should be aware of the limitations of the nerve stimulator being used. Standardisation of features is desirable when manufacturing nerve stimulators.