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Lee JH, Lee HJ, Yi KH, Lee KW, Gil YC, Kim HJ. Ideal Injection Points for Botulinum Neurotoxin for Pectoralis Minor Syndrome: A Cadaveric Study. Toxins (Basel) 2023; 15:603. [PMID: 37888634 PMCID: PMC10610843 DOI: 10.3390/toxins15100603] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/08/2023] [Revised: 09/20/2023] [Accepted: 09/26/2023] [Indexed: 10/28/2023] Open
Abstract
Pectoralis Minor Syndrome (PMS) causes significant discomfort due to the compression of the neurovascular bundle within the retropectoralis minor space. Botulinum neurotoxin (BoNT) injections have emerged as a potential treatment method; however, their effectiveness depends on accurately locating the injection site. In this study, we aimed to identify optimal BoNT injection sites for PMS treatment. We used twenty-nine embalmed and eight non-embalmed human cadavers to determine the origin and intramuscular arborization of the pectoralis minor muscle (Pm) via manual dissection and Sihler's nerve staining techniques. Our findings showed the Pm's origin near an oblique line through the suprasternal notch, with most neural arborization within the proximal three-fourths of the Pm. Blind dye injections validated these results, effectively targeting the primary neural arborized area of the Pm at the oblique line's intersection with the second and third ribs. We propose BoNT injections at the arborized region within the Pm's proximal three-fourths, or the C region, for PMS treatment. These findings guide clinicians towards safer, more effective BoNT injections.
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Affiliation(s)
- Ji-Hyun Lee
- Department of Anatomy and Acupoint, College of Korean Medicine, Gachon University, 1342 Seongnam-daero, Seongnam-si 13120, Republic of Korea;
| | - Hyung-Jin Lee
- Department of Anatomy, Catholic Institute for Applied Anatomy, College of Medicine, The Catholic University, 222 Banpo-daero, Seoul 06591, Republic of Korea;
| | - Kyu-Ho Yi
- Division in Anatomy and Developmental Biology, Department of Oral Biology, Human Identification Research Institute, BK21 FOUR Project, College of Dentistry, Yonsei University, 50-1 Yonsei-ro, Seoul 03722, Republic of Korea; (K.-H.Y.); (K.-W.L.)
| | - Kang-Woo Lee
- Division in Anatomy and Developmental Biology, Department of Oral Biology, Human Identification Research Institute, BK21 FOUR Project, College of Dentistry, Yonsei University, 50-1 Yonsei-ro, Seoul 03722, Republic of Korea; (K.-H.Y.); (K.-W.L.)
| | - Young-Chun Gil
- Department of Anatomy, College of Medicine, Chungbuk National University, 1 Chungdae-ro, Cheongju-si 28644, Republic of Korea;
| | - Hee-Jin Kim
- Division in Anatomy and Developmental Biology, Department of Oral Biology, Human Identification Research Institute, BK21 FOUR Project, College of Dentistry, Yonsei University, 50-1 Yonsei-ro, Seoul 03722, Republic of Korea; (K.-H.Y.); (K.-W.L.)
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Bomberg H, Lorenzana D, Aguirre J, Eichenberger U. [Peripheral Regional Anaesthesia for Perioperative Analgesia]. PRAXIS 2021; 110:579-589. [PMID: 34344186 DOI: 10.1024/1661-8157/a003682] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 06/13/2023]
Abstract
Peripheral Regional Anaesthesia for Perioperative Analgesia Abstract. Peripheral regional anaesthesia is the actual gold standard of opioid-sparing perioperative analgesia and is mainly used for surgery of the shoulder, arm and leg. Well-trained anaesthesiologists are the prerequisite for the correct individual risk-benefit assessment and the performance of the nerve blocks using a combination of ultrasound guidance and peripheral nerve stimulation (dual guidance). The postoperative care of the patients requires trained staff.
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Affiliation(s)
- Hagen Bomberg
- Abteilung für Anästhesiologie, Intensivmedizin und Schmerztherapie, Universitätsklinik Balgrist, Zürich
| | - David Lorenzana
- Abteilung für Anästhesiologie, Intensivmedizin und Schmerztherapie, Universitätsklinik Balgrist, Zürich
| | - José Aguirre
- Abteilung für Anästhesiologie, Intensivmedizin und Schmerztherapie, Universitätsklinik Balgrist, Zürich
| | - Urs Eichenberger
- Abteilung für Anästhesiologie, Intensivmedizin und Schmerztherapie, Universitätsklinik Balgrist, Zürich
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3
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The Electric Shock during Acupuncture: A Normal Needling Sensation or a Warning Sign. Neural Plast 2020; 2020:8834573. [PMID: 33204248 PMCID: PMC7655260 DOI: 10.1155/2020/8834573] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/25/2020] [Revised: 10/10/2020] [Accepted: 10/19/2020] [Indexed: 11/17/2022] Open
Abstract
The electric shock has been proposed as one of the new needling sensations in recent years. In acupuncture sensation scales, the electric shock is included by ASS and SNQS, but not SASS, MASS, and C-MMASS. Some scholars argue that the electric shock is a normal needling sensation, but some researchers do not agree with this view. This problem has not been resolved due to a lack of evidence from basic research. Literature and research point out that the electric shock is caused by inserting a needle into the nerve directly. A question of considerable scientific and practical interest is whether the electric shock should be a normal needling sensation. In this article, we review the historical documentation of the needling sensation and the process of formulating and improving acupuncture sensation scales to suggest that the electric shock may not be a normal needling sensation. Secondly, we collected and analyzed cases of nerve injury caused by acupuncture accompanied by the electric shock and why acupuncture caused the electric shock without nerve injury. It suggests that there may be a correlation between the electric shock and peripheral nerve injury, and acupuncture manipulation is an essential factor in adverse acupuncture events. Finally, we put forward that the electric shock during acupuncture is a warning sign that the peripheral nerve may be injured, rather than a normal needling sensation. In the future, we hope to have experimental studies on the mechanism of the electric shock or observational studies on the correlation between the electric shock and peripheral nerve injury to verify.
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Shrestha N, Karki B, Koirala M, Acharya S, Shrestha PS, Acharya SP. Delayed Neurological Recovery After Ultrasound-Guided Brachial Plexus Block: A Case Report [Response to Letter]. Local Reg Anesth 2020; 13:47-48. [PMID: 32606917 PMCID: PMC7305332 DOI: 10.2147/lra.s266326] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/05/2020] [Accepted: 06/05/2020] [Indexed: 11/23/2022] Open
Affiliation(s)
- Ninadini Shrestha
- Department of Anaesthesia, Maharajgunj Medical Campus, Institute of Medicine, Maharajgunj, Kathmandu, Nepal
| | - Bipin Karki
- Department of Critical Care Medicine, Om Hospital and Research Center Pvt. Ltd, Chabahil, Kathmandu, Nepal
| | - Megha Koirala
- Department of Anaesthesia, Maharajgunj Medical Campus, Institute of Medicine, Maharajgunj, Kathmandu, Nepal
| | - Santosh Acharya
- Department of Critical Care Medicine, Hospital for Advanced Medicine and Surgery, Dhumbarahi, Kathmandu, Nepal
| | - Pramesh Sunder Shrestha
- Department of Anaesthesia, Maharajgunj Medical Campus, Institute of Medicine, Maharajgunj, Kathmandu, Nepal
| | - Subhash Prasad Acharya
- Department of Anaesthesia, Maharajgunj Medical Campus, Institute of Medicine, Maharajgunj, Kathmandu, Nepal
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Laredo FG, Belda E, Soler M, Gil F, Murciano J, Sánchez-Campillo J, Agut A. Short-Term Effects of Deliberate Subparaneural or Subepineural Injections With Saline Solution or Bupivacaine 0.75% in the Sciatic Nerve of Rabbits. Front Vet Sci 2020; 7:217. [PMID: 32478104 PMCID: PMC7235316 DOI: 10.3389/fvets.2020.00217] [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] [Received: 01/07/2020] [Accepted: 04/01/2020] [Indexed: 11/13/2022] Open
Abstract
Background: Ultrasound (US)-guided techniques for peripheral nerve blockade have revealed that intraneural injections are relatively frequent and not necessarily associated with neurological deficits. Objectives: To evaluate the short-term effects of deliberate injections performed under direct vision in two different sites of the sciatic nerve (ScN). Material and Methods: Seventy-two New Zealand white rabbits randomly assigned to one of four experimental groups (n = 18) were employed. All procedures were conducted at a proximal femoral level where the ScN incorporates the common peroneal nerve and the tibial nerve (TN). Fixed volumes of 0.5 ml of saline solution (ES group) or bupivacaine 0.75% (EB group) were administered extrafascicularly inside the paraneurium of the ScN or intrafascicularly (IS and IB groups) under the epineurium of the TN. Cross-sectional area (CSA) and relative echogenicity (RE) of the entire ScN were determined by US before injections, after injections, and at 3 and 7 days. ScN samples were obtained for structural and ultrastructural histopathological studies. Proprioceptive, sensorial, and motor function were clinically evaluated on a daily basis. Results: The CSA of the ScN increased significantly immediately after injections when compared with pre-injection values in all groups (p < 0.05). The RE of the ScN decreased in relation to pre-injection values in all groups (p < 0.05). The CSA and RE of the ScN returned to normal values 7 days after injections in almost all groups. Injected nerves showed histological signs of mild perineural inflammation. Histopathological scores were not significantly different between groups (p > 0.05). The architecture of the ScN was preserved in all rabbits at 3 days and in 31/32 rabbits at 7 days. A focal area of damaged nerve fibers with degeneration of the axons and myelin sheath affecting the TN was observed in one rabbit of the IB group. Nerve function was not clinically impaired in any case. Conclusion: Despite the lack of severe nerve disruption observed in most rabbits, the evidence of a focal area of damaged nerve fibers in one rabbit injected intrafascicularly with bupivacaine confirms that intrafascicular injections should be avoided as they may increase the risk of nerve damage.
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Affiliation(s)
- Francisco G Laredo
- Department of Medicine and Animal Surgery, Faculty of Veterinary Science, University of Murcia, Murcia, Spain
| | - Eliseo Belda
- Department of Medicine and Animal Surgery, Faculty of Veterinary Science, University of Murcia, Murcia, Spain
| | - Marta Soler
- Department of Medicine and Animal Surgery, Faculty of Veterinary Science, University of Murcia, Murcia, Spain
| | - Francisco Gil
- Department of Comparative Anatomy and Pathological Anatomy, Faculty of Veterinary Science, University of Murcia, Murcia, Spain
| | - José Murciano
- Department of Medicine and Animal Surgery, Faculty of Veterinary Science, University of Murcia, Murcia, Spain
| | - Joaquín Sánchez-Campillo
- Department of Comparative Anatomy and Pathological Anatomy, Faculty of Veterinary Science, University of Murcia, Murcia, Spain
| | - Amalia Agut
- Department of Medicine and Animal Surgery, Faculty of Veterinary Science, University of Murcia, Murcia, Spain
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Sivashanmugam T, Sripriya R, Jayaraman G, Ravindran C, Ravishankar M. Truncal injection brachial plexus block: A Description of a novel injection technique and dose finding study. Indian J Anaesth 2020; 64:415-421. [PMID: 32724251 PMCID: PMC7286406 DOI: 10.4103/ija.ija_803_19] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/18/2019] [Revised: 01/21/2020] [Accepted: 04/08/2020] [Indexed: 11/04/2022] Open
Abstract
Background and Aims Brachial plexus (BP) blocks continue to be described with reference to anatomical landmarks (Interscalene and Supraclavicular), even after the introduction of ultrasound which enables us to directly identify the roots, trunks and divisions of the BP. The aim of this study was to describe a novel injection technique targeting trunks of BP and to determine the minimum effective local anaesthetic volume (MELAV) required to produce BP block with this approach. Methods Twenty-one male patients in the age group 20-40 years, undergoing elective forearm bony procedures received an ultrasound-guided truncal injection BP block. MELAV50 was determined using the Dixon and Mood up-and-down method. Initial volume of local anaesthetic (LA; 50:50 mixture of bupivacaine 0.5% and lignocaine 2% with 5 μg/ml epinephrine) injected was 6 ml in each trunk, which was varied by 1 ml/trunk for each consecutive patient according to the response of the previous patient. The MELAV50, MELAV95 and MELAV99 were calculated using Probit transformation and logistic regression. Results Out of the 21 patients, 13 patients had a successful block. The MELAV50, MELAV95 and MELAV99 were 7.41, 10.47 and 12 ml, respectively. Eight patients in whom block failed had sparing in the ulnar and median nerve territories. Conclusion Trunks of the brachial plexus can be identified and targeted for the injection of local anaesthetics. The MELAV50 and MELAV95 required for ultrasound-guided truncal injection brachial plexus block were 7.4 and 10.4 ml, respectively.
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Affiliation(s)
- T Sivashanmugam
- Department of Anaesthesiology, MGMCRI, SBV University, Pondicherry, India
| | - R Sripriya
- Department of Anaesthesiology, MGMCRI, SBV University, Pondicherry, India
| | - Gobinath Jayaraman
- Department of Anaesthesiology, MGMCRI, SBV University, Pondicherry, India
| | | | - M Ravishankar
- Department of Anaesthesiology, MGMCRI, SBV University, Pondicherry, India
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7
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Kuo F, Park J, Chow K, Chen A, Walsworth MK. Avoiding peripheral nerve injury in arterial interventions. ACTA ACUST UNITED AC 2020; 25:380-391. [PMID: 31310240 DOI: 10.5152/dir.2019.18296] [Citation(s) in RCA: 14] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/25/2022]
Abstract
Although peripheral nerve injuries secondary to angiography and endovascular interventions are uncommon and usually not permanent, they can result in significant functional impairment. Most arteries used in access for angiography and endovascular therapies lie in close proximity to a nerve. The nerve may be injured by needle puncture, or by compression from hematoma, pseudoaneurysm, hemostasis devices, or by manual compression with incidence in literature ranging from as low as 0.04% for femoral access in a large retrospective study to 9% for brachial and axillary access. Given the increasing frequency of endovascular arterial procedures and the increasing use of nontraditional access points, it is important that the interventionalist have a working knowledge of peripheral nerve anatomy and function as it relates to relevant arterial access sites to avoid injury.
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Affiliation(s)
- Frank Kuo
- Department of Radiology, UCLA Medical Center, David Geffen School of Medicine at UCLA, Los Angeles, CA, USA
| | - Jonathan Park
- Department of Radiology, UCLA Medical Center, David Geffen School of Medicine at UCLA, Los Angeles, CA, USA;Department of Radiology, VA Greater Los Angeles Healthcare System, Los Angeles, California
| | - Kira Chow
- Department of Radiology, UCLA Medical Center, David Geffen School of Medicine at UCLA, Los Angeles, CA, USA;Department of Radiology, VA Greater Los Angeles Healthcare System, Los Angeles, California
| | - Alice Chen
- Department of Radiology, UCLA Medical Center, David Geffen School of Medicine at UCLA, Los Angeles, CA, USA;Department of Radiology, VA Greater Los Angeles Healthcare System, Los Angeles, California
| | - Matthew K Walsworth
- Department of Radiology, UCLA Medical Center, David Geffen School of Medicine at UCLA, Los Angeles, CA, USA;Department of Radiology, VA Greater Los Angeles Healthcare System, Los Angeles, California
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8
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Scali M, Veldhoven PAH, Henselmans PWJ, Dodou D, Breedveld P. Design of an ultra-thin steerable probe for percutaneous interventions and preliminary evaluation in a gelatine phantom. PLoS One 2019; 14:e0221165. [PMID: 31483792 PMCID: PMC6726204 DOI: 10.1371/journal.pone.0221165] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/02/2019] [Accepted: 07/31/2019] [Indexed: 01/10/2023] Open
Abstract
Needles with diameter under 1 mm are used in various medical applications to limit the risk of complication and patient discomfort during the procedure. Next to a small diameter, needle steerability is an important property for reaching targets located deep inside the body accurately and precisely. In this paper, we present a 0.5-mm prototype probe which is able to steer in three dimensions (3D) without the need of axial rotation. The prototype consists of three Nitinol wires (each with a diameter of 0.125 mm) with a pre-curved tip. The wires are kept together by a stainless steel tube. Each wire is clamped to a block which translates along a leadscrew, the rotation of the latter being controlled by a wheel connected at the distal end of the leadscrew. The tip bends upon retraction of one or two wires. When pushed through a soft solid structure (e.g., a soft tissue or soft tissue phantom), the probe deflects due to off-axis forces acting on its tip by the surrounding structure. We tested the performance of the prototype into a 10% wt gelatine phantom, in terms of the predictability of the steering direction and the controllability of the final position after steering inside the substrate. The results showed that the probe steered in the direction of the retracted wire and that the final position varied from small deflections from the straight path when the wires were slightly retracted, to sharp curvatures for large wire retraction. The probe could be used in various applications, from cases where only a small correction of the path in one direction is needed to cases where the path to be followed includes obstacles and curves in multiple directions.
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Affiliation(s)
- Marta Scali
- Department of Biomechanical Engineering, Faculty of Mechanical, Maritime and Materials Engineering, Delft University of Technology, Delft, The Netherlands
- * E-mail:
| | - Paulien A. H. Veldhoven
- Department of Biomechanical Engineering, Faculty of Mechanical, Maritime and Materials Engineering, Delft University of Technology, Delft, The Netherlands
| | - Paul W. J. Henselmans
- Department of Biomechanical Engineering, Faculty of Mechanical, Maritime and Materials Engineering, Delft University of Technology, Delft, The Netherlands
| | - Dimitra Dodou
- Department of Biomechanical Engineering, Faculty of Mechanical, Maritime and Materials Engineering, Delft University of Technology, Delft, The Netherlands
| | - Paul Breedveld
- Department of Biomechanical Engineering, Faculty of Mechanical, Maritime and Materials Engineering, Delft University of Technology, Delft, The Netherlands
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Bangari DS, Pardo ID, Sellers R, Johnson JA, Ryan S, Thurberg BL. Peripheral Nerve Microscopic Changes Related to Study Procedures: Two Nonclinical Case Studies. Toxicol Pathol 2019; 48:220-227. [DOI: 10.1177/0192623319854328] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
Peripheral nerves are routinely examined microscopically during the nonclinical safety assessment of therapeutics. In addition to test article-related on- or off-target changes, microscopic changes in peripheral nerves may also be caused by study procedures, such as parenteral test article administration and blood or tissue sampling. We present 2 nonclinical case studies in which nonstandard peripheral nerves had study procedure-related histologic changes. The first case study describes mouse trigeminal nerve changes as a result of blood sampling via retro-orbital sinus puncture. These changes included minimal-to-mild nerve fiber (axonal) degeneration associated with macrophage infiltration. The second case study presents rat brachial plexus changes associated with animal handling and blood sampling. Brachial plexus changes included minimal-to-moderate inflammation, focal hemorrhage, and nerve fiber degeneration. In both cases, the histological changes were morphologically indistinguishable from those that might be due to test article. Therefore, careful consideration of the incidence and severity across groups and a review of study procedures to rule out handling-related nerve damage are essential before identifying a test article-related effect on peripheral nerves. Study design considerations to avoid such procedure-related changes will be discussed, as well as sampling strategies to help distinguish these from test article-related effects.
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Affiliation(s)
| | | | - Rani Sellers
- Drug Safety Research and Development, Pfizer Inc, Pearl River, NY, USA
| | | | - Susan Ryan
- Global Discovery Pathology, Sanofi, Framingham, MA, USA
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10
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Gadsden J, Orebaugh S. Targeted intracluster supraclavicular brachial plexus block: too close for comfort. Br J Anaesth 2019; 122:713-715. [DOI: 10.1016/j.bja.2019.02.020] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/20/2019] [Revised: 02/25/2019] [Accepted: 02/26/2019] [Indexed: 11/17/2022] Open
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Abstract
A 79-year-old woman with primary erythromelalgia underwent a left reverse total shoulder arthroplasty with a left interscalene nerve block, a superficial cervical plexus block, and a general endotracheal anesthetic, with no residual neurological deficits. Herein, we discuss the classification and pathophysiology of erythromelalgia along with the anesthetic considerations of peripheral nerve blockade in patients with primary erythromelalgia.
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O'Flaherty D, McCartney CJL, Ng SC. Nerve injury after peripheral nerve blockade-current understanding and guidelines. BJA Educ 2018; 18:384-390. [PMID: 33456806 DOI: 10.1016/j.bjae.2018.09.004] [Citation(s) in RCA: 16] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 09/21/2018] [Indexed: 10/28/2022] Open
Affiliation(s)
- D O'Flaherty
- University College London Hospitals NHS Foundation Trust, London, UK
| | - C J L McCartney
- The Ottawa Hospital, Ottawa, ON, Canada.,University of Ottawa, Ottawa, ON, Canada
| | - S C Ng
- University College London Hospitals NHS Foundation Trust, London, UK
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Abstract
Abstract
What We Already Know about This Topic
What This Article Tells Us That Is New
Background
Both extra- and intraneural sciatic injection resulted in significant axonal nerve damage. This study aimed to establish the minimum effective volume of intraneural ropivacaine 1% for complete sensory-motor sciatic nerve block in 90% of patients, and related electrophysiologic variations.
Methods
Forty-seven consecutive American Society of Anesthesiologists physical status I-II patients received an ultrasound-guided popliteal intraneural nerve block following the up-and-down biased coin design. The starting volume was 15 ml. Baseline, 5-week, and 6-month electrophysiologic tests were performed. Amplitude, latency, and velocity were evaluated. A follow-up telephone call at 6 months was also performed.
Results
The minimum effective volume of ropivacaine 1% in 90% of patients for complete sensory-motor sciatic nerve block resulted in 6.6 ml (95% CI, 6.4 to 6.7) with an onset time of 19 ± 12 min. Success rate was 98%. Baseline amplitude of action potential (mV) at ankle, fibula, malleolus, and popliteus were 8.4 ± 2.3, 7.1 ± 2.0, 15.4 ± 6.5, and 11.7 ± 5.1 respectively. They were significantly reduced at the fifth week (4.3 ± 2.1, 3.5 ± 1.8, 6.9 ± 3.7, and 5.2 ± 3.0) and at the sixth month (5.9 ± 2.3, 5.1 ± 2.1, 10.3 ± 4.0, and 7.5 ± 2.7) (P < 0.001 in all cases). Latency and velocity did not change from the baseline. No patient reported neurologic symptoms at 6-month follow-up.
Conclusions
The intraneural ultrasound-guided popliteal local anesthetic injection significantly reduces the local anesthetic dose to achieve an effective sensory-motor block, decreasing the risk of systemic toxicity. Persistent electrophysiologic changes suggest possible axonal damage that will require further investigation.
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Krol A, Vala A, Phylactides L, Szarko M, Reina MA, De Andres J. Injection pressure mapping of intraneural vs. perineural injections: further lessons from cadaveric studies. Minerva Anestesiol 2018; 84:907-918. [DOI: 10.23736/s0375-9393.18.12230-9] [Citation(s) in RCA: 13] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/08/2022]
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15
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Tseng KY, Wang HC, Chang LL, Cheng KI. Advances in Experimental Medicine and Biology: Intrafascicular Local Anesthetic Injection Damages Peripheral Nerve-Induced Neuropathic Pain. ADVANCES IN EXPERIMENTAL MEDICINE AND BIOLOGY 2018; 1099:65-76. [PMID: 30306515 DOI: 10.1007/978-981-13-1756-9_6] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 12/11/2022]
Abstract
Peripheral nerve blockade (PNB) is advantageous for patients undergoing surgery to decrease the perioperative opioid consumptions and enhance recovery after surgery.Inadvertent local anesthetic (LA) administration into nerve fiber intrafascicularly easily results in unrecognized nerve injury. Using nerve block guidance either by ultrasound, electrical nerve stimulator, or using pressure devices does not prevent nerve damage, even though most of the nerve injury is transiently. The incidence of neurologic symptoms or neuropathy is in the range of 0.02-2.2%, and no significant difference of postoperative neurologic symptoms is found as compared with using ultrasound or guided nerve stimulator technique. However, intrafascicular lidocaine brought about macrophage migration into the damaged fascicle, Schwann cell proliferation, increased intensity of myelin basic protein, and shorten withdrawal time to mechanical stimuli. In dorsal root ganglion (DRG), intrafascicular LA injection increased the activated transcriptional factor 3 (ATF-3) and downregulated Nav1.8 (Nav1.8). In spinal dorsal horn (SDH), the microglia and astrocytes located in SDH were activated and proliferated after intrafascicular LA injection and returned to baseline gradually at the end of the month. This is a kind of neuropathic pain, so low injection pressure should be maintained, the correct needle bevel used, nerve stimulator or ultrasound guidance applied, and careful and deliberately slow injection employed as important parts of the injection technique to prevent intrafascicular LA administration-induced neuropathic pain.
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Affiliation(s)
- Kuang-Yi Tseng
- Department of Anesthesiology, Kaohsiung Medical University Hospital, Kaohsiung Medical University, Kaohsiung, Taiwan.,Graduate Institute of Medicine, College of Medicine, Kaohsiung Medical University, Kaohsiung, Taiwan
| | - Hung-Chen Wang
- Department of Neurosurgery, Chang Gung Memorial Hospital, Kaohsiung Medical Center, Chang Gung University College of Medicine, Kaohsiung, Taiwan
| | - Lin-Li Chang
- Department of Microbiology and Immunology, Kaohsiung Medical University, Kaohsiung, Taiwan.,Department of Medical Research, Kaohsiung Medical University Hospital, Kaohsiung Medical University, Kaohsiung, Taiwan
| | - Kuang-I Cheng
- Department of Anesthesiology, Kaohsiung Medical University Hospital, Kaohsiung Medical University, Kaohsiung, Taiwan. .,Graduate Institute of Medicine, College of Medicine, Kaohsiung Medical University, Kaohsiung, Taiwan.
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16
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17
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Sondekoppam RV, Tsui BCH. Factors Associated With Risk of Neurologic Complications After Peripheral Nerve Blocks. Anesth Analg 2017; 124:645-660. [DOI: 10.1213/ane.0000000000001804] [Citation(s) in RCA: 45] [Impact Index Per Article: 6.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
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18
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Wiesmann T, Steinfeldt T, Exner M, Nimphius W, De Andres J, Wulf H, Schwemmer U. Intraneural injection of a test dose of local anesthetic in peripheral nerves - does it induce histological changes in nerve tissue? Acta Anaesthesiol Scand 2017; 61:91-98. [PMID: 27778324 DOI: 10.1111/aas.12825] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/18/2016] [Revised: 09/01/2016] [Accepted: 09/29/2016] [Indexed: 12/20/2022]
Abstract
BACKGROUND & OBJECTIVES Most anesthesiologists use the injection of a test dose of local anesthetic in order to evaluate the final needle tip position. Thus, the intraneural injection of a full dose can be avoided. The aim of this study was to analyze whether an intraneural injection of a test dose of bupivacaine could trigger histological changes. METHODS Intraneural injections under direct vision were performed in 40 brachial plexus nerves in seven anesthetized pigs. Tibial nerves served as positive and negative controls. Two milliliter of bupivacaine 0.5% was injected in three nerves on the left brachial plexus. For control of local anesthetic's toxicity Ringer's solution was applied intraneurally on the right side. After maintaining 48 h of general anesthesia, the nerves were resected. The specimens were processed for histological examination and assessed for inflammation (hematoxylin and eosin stain, CD68-immunohistochemistry) and myelin damage (Kluver-Barrera stain). The degree of nerve injury was rated on a scale from 0 (no injury) to 4 (severe injury). RESULTS Statistical analysis showed no significant differences between the bupivacaine group [median (interquartile range) 1 (1-1.5)] and the Ringer's solution group [1 (0.5-2) P = 0.772]. Mild myelin alteration was found in 12.5% of all specimens following intraneural injection, irrespective of the applied substance. CONCLUSIONS "In our experimental study, intraneural injection of 2 ml of bupivacaine or Ringer's solution showed comparable mild inflammation. Nevertheless, inflammation can only be prevented by strictly avoiding nerve perforation followed by intraneural injection, as mechanical nerve perforation is a key factor for evolving inflammation.
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Affiliation(s)
- T. Wiesmann
- Department of Anesthesia and Intensive Care; University Hospital Marburg; Marburg Germany
| | - T. Steinfeldt
- Department of Anesthesia and Intensive Care; University Hospital Marburg; Marburg Germany
- Department of Anesthesia and Intensive Care Medicine; Diakonie-Klinikum Schwaebisch Hall; Schwaebisch Hall Germany
| | - M. Exner
- Department of Anesthesia and Intensive Care; University Hospital Marburg; Marburg Germany
| | - W. Nimphius
- Department of Pathology; University Hospital Marburg; Marburg Germany
| | - J. De Andres
- Anesthesia Division; Department of Surgery; Valencia School of Medicine; Valencia Spain
| | - H. Wulf
- Department of Anesthesia and Intensive Care; University Hospital Marburg; Marburg Germany
| | - U. Schwemmer
- Department of Anesthesiology & Critical Care; Klinikum Neumarkt; Neumarkt i.d.OPf. Germany
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Munirama S, Zealley K, Schwab A, Columb M, Corner G, Eisma R, McLeod G. Trainee anaesthetist diagnosis of intraneural injection—a study comparing B-mode ultrasound with the fusion of B-mode and elastography in the soft embalmed Thiel cadaver model. Br J Anaesth 2016; 117:792-800. [DOI: 10.1093/bja/aew337] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 09/13/2016] [Indexed: 11/13/2022] Open
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Development of a peripheral nerve stimulator-guided technique for equine pudendal nerve blockade. Vet J 2016; 217:72-77. [PMID: 27810215 DOI: 10.1016/j.tvjl.2016.10.004] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/30/2016] [Revised: 10/03/2016] [Accepted: 10/05/2016] [Indexed: 11/23/2022]
Abstract
The aim of this study was to develop and evaluate a procedure for equine pudendal nerve block using a peripheral nerve locator. In the first experiment, six ponies were used to determine the relationship between elicited muscle contractions (anal, perineal or both) and nerves serving the perineal region (pudendal, caudorectal and perineal nerves) when methylene blue dye was injected using the electrolocation technique. This experiment showed that the pudendal nerve was approached effectively when both anal and perineal twitch were elicited during electrolocation. In a second experiment, seven Thoroughbred horses were used to evaluate the appropriate volume of anaesthetic solution for the nerve block. Immediately after euthanasia, lidocaine/methylene blue solution was injected after positive electrolocation. A stained segment of 2 cm or more of the nerve was considered effective and this was evaluated after dissection. Both 10 and 20 mL per injection site resulted in effective nerve staining. Finally, pudendal nerve block was performed and evaluated in 27 horses admitted for selected reproductive surgical procedures including perineoplasty, urethroplasty, clitorectomy in mares and penile examination, phallectomy and urethrostomy in geldings. Surgical time varied from several minutes to 3 h. The choice between lidocaine, mepivacaine or bupivacaine was based on the duration of analgesia required. In mares and males, a volume of 20 mL and 10 mL, respectively, was injected per site. The use of a peripheral nerve stimulator-guided pudendal nerve block is a feasible, safe and reliable alternative for both epidural and general anaesthesia, to provide peri-operative analgesia in clinical equine patients undergoing specific reproductive surgeries.
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Kirchmair L, Ströhle M, Löscher WN, Kreutziger J, Voelckel WG, Lirk P. Neurophysiological effects of needle trauma and intraneural injection in a porcine model: a pilot study. Acta Anaesthesiol Scand 2016; 60:393-9. [PMID: 26611997 DOI: 10.1111/aas.12657] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/26/2015] [Revised: 08/06/2015] [Accepted: 10/08/2015] [Indexed: 12/19/2022]
Abstract
BACKGROUND Neurophysiological data are lacking in the research of nerve injury during regional anaesthesia. The aim of this pilot study was to establish a large animal model in order to test the hypothesis that needle trauma alone or in combination with intraneural injection would result in measurable nerve injury. METHODS The experimental set-up was elaborated in four pre-test animals. In the remaining animals (n = 11), 22 sciatic nerves were randomly assigned to one of four groups: needle trauma (n = 5) generated by ultrasound-guided forced needle advancement; intraneural injection of 2.5 ml saline (n = 6); intraneural injection of 5 ml saline (n = 6); extraneural injection of 5 ml saline (n = 5) as control group. Compound muscle action potential (CMAP) amplitudes as well as latencies were taken as outcome parameter and monitored over 180 min. Sonographic assessments were performed simultaneously. RESULTS Following needle trauma and intraneural injection, CMAP amplitudes declined significantly over 180 min (P < 0.001). The control group showed no electrophysiological alterations. At 60 min, decreases in amplitude were significant after needle trauma (P = 0.04) and intraneural injection of 2.5 ml (P = 0.045), and highly significant after injection of 5 ml (P = 0.006) when compared to controls. Sustained nerve swelling was observed after intraneural injection, but not after needle trauma and perineural injection. CONCLUSIONS Isolated mechanical trauma caused by forced needle advancement alone or in combination with intraneural injection of saline was followed by a significant decline in CMAP amplitudes indicating conduction block due to disruption of myelin or axon loss (pseudo-conduction block).
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Affiliation(s)
- L. Kirchmair
- Department of Anaesthesiology and Critical Care Medicine; AUVA Trauma Centre Salzburg; Salzburg Austria
- Paracelsus Medical University Salzburg; Salzburg Austria
| | - M. Ströhle
- Department of Anaesthesiology and Critical Care Medicine; Innsbruck Medical University; Innsbruck Austria
| | - W. N. Löscher
- Department of Neurology; Innsbruck Medical University; Innsbruck Austria
| | - J. Kreutziger
- Department of Anaesthesiology and Critical Care Medicine; Innsbruck Medical University; Innsbruck Austria
| | - W. G. Voelckel
- Department of Anaesthesiology and Critical Care Medicine; AUVA Trauma Centre Salzburg; Salzburg Austria
- Paracelsus Medical University Salzburg; Salzburg Austria
| | - P. Lirk
- Department of Anaesthesiology; Academic Medical Centre; University of Amsterdam; Amsterdam The Netherlands
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Damjanovska M, Cvetko E, Hadzic A, Seliskar A, Plavec T, Mis K, Vuckovic Hasanbegovic I, Stopar Pintaric T. Neurotoxicity of perineural vs intraneural-extrafascicular injection of liposomal bupivacaine in the porcine model of sciatic nerve block. Anaesthesia 2015; 70:1418-26. [PMID: 26338496 PMCID: PMC5049634 DOI: 10.1111/anae.13189] [Citation(s) in RCA: 24] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 06/25/2015] [Indexed: 11/30/2022]
Abstract
Liposomal bupivacaine is a prolonged-release local anaesthetic, the neurotoxicity of which has not yet been determined. We used quantitative histomorphometric and immunohistochemical analyses to evaluate the neurotoxic effect of liposomal bupivacaine after perineural and intraneural (extrafascicular) injection of the sciatic nerve in pigs. In this double-blind prospective randomised trial, 4 ml liposomal bupivacaine 1.3% was injected either perineurally (n = 5) or intraneurally extrafascicularly (n = 5). Intraneural-extrafascicular injection of saline (n = 5) was used as a control. After emergence from anaesthesia, neurological examinations were conducted over two weeks. After harvesting the sciatic nerves, no changes in nerve fibre density or myelin width indicative of nerve injury were observed in any of the groups. Intraneural injections resulted in longer sensory blockade than perineural (p < 0.003) without persistent motor or sensory deficit. Sciatic nerve block with liposomal bupivacaine in pigs did not result in histological evidence of nerve injury.
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Affiliation(s)
- M. Damjanovska
- Clinical Department of Anaesthesiology and Intensive TherapyUniversity Medical Centre LjubljanaLjubljanaSlovenia
| | - E. Cvetko
- Institute of AnatomyFaculty of MedicineUniversity of LjubljanaLjubljanaSlovenia
| | - A. Hadzic
- NAICE (North American Institute for Continuing Education)New YorkNYUSA
- NYSORA (The New York School of Regional Anesthesia)New YorkNYUSA
- Department of AnesthesiologyZiekenhuis Oost‐LimburgGenkBelgium
| | - A. Seliskar
- Clinic for Small Animal Medicine and SurgeryVeterinary FacultyUniversity of LjubljanaLjubljanaSlovenia
| | - T. Plavec
- Clinic for Small Animal Medicine and SurgeryVeterinary FacultyUniversity of LjubljanaLjubljanaSlovenia
| | - K. Mis
- Institute of PathophysiologyFaculty of MedicineUniversity of LjubljanaLjubljanaSlovenia
| | | | - T. Stopar Pintaric
- Clinical Department of Anaesthesiology and Intensive TherapyUniversity Medical Centre LjubljanaLjubljanaSlovenia
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Erkutlu I, Alptekin M, Geyik S, Geyik AM, Gezgin I, Gök A. Early cyclosporin A treatment retards axonal degeneration in an experimental peripheral nerve injection injury model. Neural Regen Res 2015; 10:266-70. [PMID: 25883626 PMCID: PMC4392675 DOI: 10.4103/1673-5374.152381] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 11/22/2014] [Indexed: 11/16/2022] Open
Abstract
Injury to peripheral nerves during injections of therapeutic agents such as penicillin G potassium is common in developing countries. It has been shown that cyclosporin A, a powerful immunosuppressive agent, can retard Wallerian degeneration after peripheral nerve crush injury. However, few studies are reported on the effects of cyclosporin A on peripheral nerve drug injection injury. This study aimed to assess the time-dependent efficacy of cyclosporine-A as an immunosuppressant therapy in an experimental rat nerve injection injury model established by penicillin G potassium injection. The rats were randomly divided into three groups based on the length of time after nerve injury induced by cyclosporine-A administration (30 minutes, 8 or 24 hours). The compound muscle action potentials were recorded pre-injury, early post-injury (within 1 hour) and 4 weeks after injury and compared statistically. Tissue samples were taken from each animal for histological analysis. Compared to the control group, a significant improvement of the compound muscle action potential amplitude value was observed only when cyclosporine-A was administered within 30 minutes of the injection injury (P < 0.05); at 8 or 24 hours after cyclosporine-A administration, compound muscle action potential amplitude was not changed compared with the control group. Thus, early immunosuppressant drug therapy may be a good alternative neuroprotective therapy option in experimental nerve injection injury induced by penicillin G potassium injection.
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Affiliation(s)
- Ibrahim Erkutlu
- Department of Neurosurgery, Faculty of Medicine, University of Gaziantep, Gaziantep, Turkey
| | - Mehmet Alptekin
- Department of Neurosurgery, Faculty of Medicine, University of Gaziantep, Gaziantep, Turkey
| | - Sirma Geyik
- Department of Neurology, Faculty of Medicine, University of Gaziantep, Gaziantep, Turkey
| | | | - Inan Gezgin
- Department of Neurosurgery, Private Park Hospital, Adıyaman, Turkey
| | - Abdulvahap Gök
- Department of Neurosurgery, Faculty of Medicine, University of Gaziantep, Gaziantep, Turkey
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Steinfeldt T, Wiesmann T. Needle-nerve proximity during peripheral nerve blocks--where is the right target and how can we get there? REVISTA ESPANOLA DE ANESTESIOLOGIA Y REANIMACION 2015; 62:121-124. [PMID: 25677677 DOI: 10.1016/j.redar.2015.01.006] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 01/18/2015] [Accepted: 01/19/2015] [Indexed: 06/04/2023]
Affiliation(s)
- T Steinfeldt
- Anaesthesiologist, Consultant; Dep. of Anaesthesia and Intensive Care Therapy, Philipps University Hospital, Philipps-University, Baldingerstr., 35033 Marburg, Germany.
| | - T Wiesmann
- Anaesthesiologist, Staff; Dep. of Anaesthesia and Intensive Care Therapy, Philipps University Hospital, Philipps-University, Baldingerstr., 35033 Marburg, Germany
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Ultrasound-guided administration of lidocaine into the sciatic nerve in a porcine model: Correlation between the ultrasonographic evolution of the lesions, locomotor function and histological findings. Vet J 2014; 200:170-4. [DOI: 10.1016/j.tvjl.2014.01.027] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/19/2013] [Revised: 01/30/2014] [Accepted: 01/31/2014] [Indexed: 11/17/2022]
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Permanent Diaphragm Paralysis after Shoulder Rotator Cuff Repair: Interscalene Block Is Not the Only Factor. Anesthesiology 2014; 120:1054-6. [DOI: 10.1097/aln.0000000000000128] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
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Distale Blockaden des N. ischiadicus. Anaesthesist 2013; 62:183-88, 190-2. [DOI: 10.1007/s00101-013-2150-5] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/30/2012] [Revised: 01/18/2013] [Accepted: 01/29/2013] [Indexed: 11/25/2022]
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Gorsewski G, Dinse-Lambracht A, Tugtekin I, Gauss A. Ultraschallgesteuerte periphere Regionalanästhesie. Anaesthesist 2012; 61:711-21. [DOI: 10.1007/s00101-012-2045-x] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/31/2022]
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Histological Consequences of Needle-Nerve Contact following Nerve Stimulation in a Pig Model. Anesthesiol Res Pract 2011; 2011:591851. [PMID: 21716736 PMCID: PMC3119464 DOI: 10.1155/2011/591851] [Citation(s) in RCA: 10] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/21/2010] [Accepted: 02/23/2011] [Indexed: 11/18/2022] Open
Abstract
Background. Nerve stimulation can facilitate correct needle placement in peripheral regional anesthesia. The aim of this study was to determine whether the high threshold current is associated with reduced nerve injury due to fewer needle-nerve contacts compared with low current. Methods. In anaesthetized pigs, thirty-two nerves of the brachial plexus underwent needle placement at low (0.2 mA) or high current (1.0 mA). The occurrence of needle-nerve contact was recorded. After 48 hours, the nerves were analyzed for occurrence of histological changes. Nerve injury was scored ranging from 0 (no injury) to 4 (severe injury). Results. The frequency of needle-nerve contact was 94% at low compared to 6% at high current. The score was significantly higher at low (median [interquartile range] 2.0 [1.0-2.0]) compared to high current (0.0 [0.0-1.0] P = .001). Conclusions. Inflammatory responses were directly related to needle-nerve contacts. Hence, posttraumatic inflammation may be diminished using higher current for nerve localization.
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Paraskevas GK, Raikos A, Chouliaras K, Papaziogas B. Variable anatomical relationship of phrenic nerve and subclavian vein: clinical implication for subclavian vein catheterization. Br J Anaesth 2011; 106:348-51. [PMID: 21233111 DOI: 10.1093/bja/aeq373] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/12/2022] Open
Abstract
BACKGROUND During subclavian vein catheterization, a potential, but rare, hazard is the phrenic nerve injury, which compromises respiratory function. We conducted a cadaver study focused on the possible anatomical relationships between the subclavian vein and the phrenic nerve. METHODS Forty-two adult cadavers (84 heminecks) were dissected. Special attention was given to the topography of the phrenic nerve and subclavian vein. RESULTS In all but three cases (81 of 84), normal topography was present, that is, the nerve was posterior to the vein. In two cases, the phrenic nerve crossed anterior to the subclavian vein and in one case traversed the anterior wall of the subclavian vein. CONCLUSIONS Variants of the relationship of the subclavian vein and the phrenic nerve should be familiar to anaesthesiologists during subclavian vein cannulation in order to achieve successful vein approach without causing phrenic nerve palsy.
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Affiliation(s)
- G K Paraskevas
- Department of Anatomy, Medical School of Aristotle University of Thessaloniki, PO Box 300, 54124 Thessaloniki, Greece.
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Sell A. Nerve injury by needle nerve perforation in regional anaesthesia. Br J Anaesth 2010; 105:94; author reply 94-5. [PMID: 20551032 DOI: 10.1093/bja/aeq149] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/14/2022] Open
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