The effects of the single or multiple injection technique on the onset time of femoral nerve blocks with 0.75% ropivacaine

A comparison of the analgesic efficacy of transforaminal methylprednisolone alone and with low doses of clonidine in lumbo-sacral radiculopathy

Background:

Although transforaminal epidural steroid injections under fluoroscopic guidance have become a common mode of treatment of lumbosacral radiculopathy due to herniated disc, the efficacy of steroid with low doses of clonidine has not been compared yet.

Objectives:

Comparison of the analgesic efficacy of methylprednisolone alone and with low doses of clonidine for transforaminal injection in lumbosacral radiculopathy.

Study Design:

A randomized, double-blind trial.

Setting:

This study was performed at the Pain Clinic under the Department of Anaesthesiology, Jawaharlal Nehru Medical College Hospital, Aligarh Muslim University, Aligarh, India.

Methods:

One hundred and eighty ASA grade I and II patients aged between 18 and 55 years were allocated into groups I, II and III to receive methylprednisolone 60 mg alone or methylprednisolone 60 mg with or without low doses of clonidine (0.5 mcg/kg or 1 mcg/kg) as transforaminal epidural injection. Pain relief and patient's satisfaction were evaluated with the global pain scale. Follow-up visits were advised at 1, 2, 4, 6 and 12 weeks and then at 6 months after injection. Associated complications were recorded.

Results:

Maximum pain relief was observed at 2 weeks after injection in all the three groups, with no difference in complication rate among the three groups. The most common complication observed was paresthesia in the nerve distribution. Greater than 60% improvement in pain scores was seen in 40% of the patients in group I, 50% of the patients in group II and 75% of the patients in group III.

Limitations:

This study is limited by the lack of a placebo group.

Conclusion:

Adding 1 mcg/kg clonidine to 60 mg methylprednisolone in transforaminal epidural injections provided better pain relief than 60 mg methylprednisolone with 0.5 mcg/kg clonidine or 60 mg methylprednisolone alone in patients suffering from lumbosacral radiculopathy, with practically no significant side-effects.

Effect of clonidine as adjuvant in bupivacaine-induced supraclavicular brachial plexus block: A randomized controlled trial

Objective:

Clonidine has been used as adjuvant to local anesthetics in order to extend the duration of analgesia in various regional and central neuraxial blocks. It is previously reported that clonidine added to bupivacaine increases analgesia duration in brachial plexus block. We evaluated the effect of this combination in supraclavicular brachial plexus block for upper limb orthopedic procedures.

Materials and Methods:

A randomized double-blind placebo controlled trial was done with 70 patients of American Society of Anesthesiologists Grade I or II status undergoing upper limb orthopedic procedures. Group A (n = 35) patients received 25 ml of 0.5% bupivacaine and 0.2 ml (30 mcg) clonidine, whereas group B (n = 35) received 25 ml of 0.5% bupivacaine and 0.2 ml normal saline through a supraclavicular approach for brachial plexus block. Vital parameters were recorded 10 min prior to block placement and every 3 min thereafter till the end of the procedure. Onset and duration of both sensory and motor blocks and sedation score were recorded. All patients were observed in postanesthesia care unit and received tramadol injection as soon as they complained of pain as rescue analgesic. Duration of analgesia was taken as the time from placement of block till injection of rescue analgesic.

Results:

Analgesia duration was 415.4 ± 38.18 min (mean ± standard deviation) in Group A (clonidine) compared to 194.2 ± 28.74 min in Group B (control). No clinically significant difference was observed in heart rate, blood pressure, and oxygen saturation. Sedation score was higher in the clonidine group.

Conclusion:

Addition of a small dose of clonidine to 0.5% bupivacaine significantly prolonged the duration of analgesia without producing any clinically important adverse reactions other than sedation.

A comparison of single versus multiple injections on the extent of anesthesia with coracoid infraclavicular brachial plexus block

Single-injection coracoid infraclavicular brachial plexus block produces inconsistent anesthesia of the upper limb. In this study, we sought to determine the number of injections needed to provide a reasonably complete anesthesia of the upper limb with this approach. Seventy-five patients were randomly assigned to receive a coracoid block guided by nerve stimulator with 42 mL of 1.5% mepivacaine with a single-injection (Group 1), dual-injection (Group 2), or triple-injection (Group 3) technique. No search for a specific motor response was performed in any group. Sensory and motor block was assessed 5 and 20 min after the end of the injection of local anesthetic. Significantly less complete anesthesia to pinprick in the distributions of the axillary, musculocutaneous, radial, ulnar, and medial cutaneous forearm nerves was found in Group 1 at 20 min. Significantly less complete paralysis for arm, wrist, and hand movements was found in Group 1 at 20 min. No significant difference was found between Groups 2 and 3. We conclude that dual and triple injection of local anesthetic guided by nerve stimulator increases the efficacy of coracoid block when compared with a single-injection technique.

Regional anaesthesia for orthopaedic surgery

Recently, there has been considerable interest in regional anaesthetic techniques, particularly in peripheral nerve blockade, for orthopaedic limb surgery. Many traditional nerve-block techniques have been significantly modified to improve their role in both in-patient and out-patient surgery. The introduction of long-acting local anaesthetic with a better safety profile as well as better equipment for continuous nerve blockade has further increased the use of such techniques in the provision of postoperative analgesia. The recent developments described in this review are likely to result in wider use of these techniques in years to come.