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Benzon HT, Elmofty D, Shankar H, Rana M, Chadwick AL, Shah S, Souza D, Nagpal AS, Abdi S, Rafla C, Abd-Elsayed A, Doshi TL, Eckmann MS, Hoang TD, Hunt C, Pino CA, Rivera J, Schneider BJ, Stout A, Stengel A, Mina M, FitzGerald JD, Hirsch JA, Wasan AD, Manchikanti L, Provenzano DA, Narouze S, Cohen SP, Maus TP, Nelson AM, Shanthanna H. Use of corticosteroids for adult chronic pain interventions: sympathetic and peripheral nerve blocks, trigger point injections - guidelines from the American Society of Regional Anesthesia and Pain Medicine, the American Academy of Pain Medicine, the American Society of Interventional Pain Physicians, the International Pain and Spine Intervention Society, and the North American Spine Society. Reg Anesth Pain Med 2024:rapm-2024-105593. [PMID: 39019502 DOI: 10.1136/rapm-2024-105593] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/23/2024] [Accepted: 06/14/2024] [Indexed: 07/19/2024]
Abstract
BACKGROUND There is potential for adverse events from corticosteroid injections, including increase in blood glucose, decrease in bone mineral density and suppression of the hypothalamic-pituitary axis. Published studies note that doses lower than those commonly injected provide similar benefit. METHODS Development of the practice guideline was approved by the Board of Directors of American Society of Regional Anesthesia and Pain Medicine with several other societies agreeing to participate. The scope of guidelines was agreed on to include safety of the injection technique (landmark-guided, ultrasound or radiology-aided injections); effect of the addition of the corticosteroid on the efficacy of the injectate (local anesthetic or saline); and adverse events related to the injection. Based on preliminary discussions, it was decided to structure the topics into three separate guidelines as follows: (1) sympathetic, peripheral nerve blocks and trigger point injections; (2) joints; and (3) neuraxial, facet, sacroiliac joints and related topics (vaccine and anticoagulants). Experts were assigned topics to perform a comprehensive review of the literature and to draft statements and recommendations, which were refined and voted for consensus (≥75% agreement) using a modified Delphi process. The United States Preventive Services Task Force grading of evidence and strength of recommendation was followed. RESULTS This guideline deals with the use and safety of corticosteroid injections for sympathetic, peripheral nerve blocks and trigger point injections for adult chronic pain conditions. All the statements and recommendations were approved by all participants after four rounds of discussion. The Practice Guidelines Committees and Board of Directors of the participating societies also approved all the statements and recommendations. The safety of some procedures, including stellate blocks, lower extremity peripheral nerve blocks and some sites of trigger point injections, is improved by imaging guidance. The addition of non-particulate corticosteroid to the local anesthetic is beneficial in cluster headaches but not in other types of headaches. Corticosteroid may provide additional benefit in transverse abdominal plane blocks and ilioinguinal/iliohypogastric nerve blocks in postherniorrhaphy pain but there is no evidence for pudendal nerve blocks. There is minimal benefit for the use of corticosteroids in trigger point injections. CONCLUSIONS In this practice guideline, we provided recommendations on the use of corticosteroids in sympathetic blocks, peripheral nerve blocks, and trigger point injections to assist clinicians in making informed decisions.
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Affiliation(s)
- Honorio T Benzon
- Anesthesiology, Feinberg School of Medicine, Chicago, Illinois, USA
| | - Dalia Elmofty
- Department of Anesthesia, University of Chicago Medical Center, Chicago, Illinois, USA
| | - Hariharan Shankar
- Anesthesiology, Clement Zablocki VA Medical Center/Medical College of Wisconsin, Milwaukee, Wisconsin, USA
| | - Maunak Rana
- Department of Anesthesia, University of Chicago Medical Center, Chicago, Illinois, USA
| | - Andrea L Chadwick
- Anesthesiology, University of Kansas Medical Center, Kansas City, Kansas, USA
| | - Shalini Shah
- University of California Irvine, Orange, California, USA
| | - Dmitri Souza
- Pain Medicine, Western Reserve Hospital, Cuyahoga Falls, Ohio, USA
| | - Ameet S Nagpal
- Orthopaedics and PM&R, Medical University of South Carolina, Charleston, South Carolina, USA
| | - Salahadin Abdi
- Pain Medicine, MD Anderson Cancer Center, Houston, Texas, USA
| | - Christian Rafla
- Anesthesiology, Loma Linda University Medical Center, Loma Linda, California, USA
| | - Alaa Abd-Elsayed
- University of Wisconsin Madison School of Medicine and Public Health, Madison, Wisconsin, USA
| | - Tina L Doshi
- Anesthesiology and Critical Care Medicine, Johns Hopkins Medicine, Baltimore, Maryland, USA
| | - Maxim S Eckmann
- Anesthesiology, University of Texas Health Science Center at San Antonio, San Antonio, Texas, USA
| | - Thanh D Hoang
- Endocrinology, Walter Reed National Military Medical Center, Bethesda, Maryland, USA
| | | | - Carlos A Pino
- Anesthesiology, Naval Medical Center San Diego, San Diego, California, USA
| | | | - Byron J Schneider
- PM&R, Vanderbilt University Medical Center, Nashville, Tennessee, USA
| | | | - Angela Stengel
- American Society of Regional Anesthesia and Pain Medicine, Pittsburgh, Pennsylvania, USA
| | - Maged Mina
- Anesthesiology, The University of Texas Health Science Center at San Antonio, San Antonio, Texas, USA
| | | | - Joshua A Hirsch
- Department of Radiology, Massachusetts General Hospital, Boston, Massachusetts, USA
| | - Ajay D Wasan
- University of Pittsburgh Health Sciences, Pittsburgh, Pennsylvania, USA
| | | | | | - Samer Narouze
- Anesthesia, Division of Pain Medicine, University Hospitals Cleveland Medical Center, Cleveland, Ohio, USA
| | - Steven P Cohen
- Anesthesiology, Feinberg School of Medicine, Chicago, Illinois, USA
- Anesthesiology, Walter Reed National Military Medical Center, Bethesda, Maryland, USA
| | | | - Ariana M Nelson
- Department of Anesthesiology and Perioperative Medicine, University of California Irvine, Irvine, California, USA
- Department of Aerospace Medicine, Exploration Medical Capability, Johnson Space Center
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Thanaboriboon C, Vargas MA, Alexopoulos K, Perez J. Phrenic Nerve Block for Diaphragmatic Pain: Case Report. A A Pract 2024; 18:e01816. [PMID: 39008447 DOI: 10.1213/xaa.0000000000001816] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 07/17/2024]
Abstract
Referred chronic shoulder pain may arise from diaphragmatic irritation. It can potentially be alleviated by blockade of the phrenic nerve. There is literature describing its use in acute pain conditions; yet for chronic pain, there are no reports. We present 2 cases of chronic diaphragmatic irritation causing ipsilateral referred shoulder pain. Patients experienced significant pain relief and a reduction in opioid consumption after receiving an ultrasound-guided phrenic nerve block. While the phrenic nerve block shows promise for pain relief, carefully evaluating its benefits and risks is recommended before considering its application in selected cases.
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Affiliation(s)
- Chanon Thanaboriboon
- From the Department of Anesthesiology, King Chulalongkorn Memorial Hospital and Faculty of Medicine, Chulalongkorn University, Bangkok, Thailand
- Department of Anesthesiology, McGill University, Montreal, Quebec, Canada
- Alan Edwards Pain Management Unit, McGill University Health Centre, Montreal, Quebec, Canada
| | - Marta A Vargas
- Department of Anesthesia, Hospital Maximiliano Peralta, Cartago, Costa Rica
| | | | - Jordi Perez
- Department of Anesthesiology, McGill University, Montreal, Quebec, Canada
- Alan Edwards Pain Management Unit, McGill University Health Centre, Montreal, Quebec, Canada
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Pérez-Montalbán M, García-Domínguez E, Oliva-Pascual-Vaca Á. Subdiaphragmatic phrenic nerve supply: A systematic review. Ann Anat 2024; 254:152269. [PMID: 38692333 DOI: 10.1016/j.aanat.2024.152269] [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: 03/05/2024] [Revised: 04/18/2024] [Accepted: 04/23/2024] [Indexed: 05/03/2024]
Abstract
OBJECTIVE The aim of this systematic review is to study the subdiaphragmatic anatomy of the phrenic nerve. MATERIALS AND METHODS A computerised systematic search of the Web of Science database was conducted. The key terms used were phrenic nerve, subdiaphragmat*, esophag*, liver, stomach, pancre*, duoden*, intestin*, bowel, gangli*, biliar*, Oddi, gallbladder, peritone*, spleen, splenic, hepat*, Glisson, falciform, coronary ligament, kidney, suprarenal, and adrenal. The 'cited-by' articles were also reviewed to ensure that all appropriate studies were included. RESULTS A total of one thousand three hundred and thirty articles were found, of which eighteen met the inclusion and exclusion criteria. The Quality Appraisal for Cadaveric Studies scale revealed substantial to excellent methodological quality of human studies, while a modified version of the Systematic Review Centre for Laboratory Animal Experimentation Risk of Bias Tool denoted poor methodological quality of animal studies. According to human studies, phrenic supply has been demonstrated for the gastro-esophageal junction, stomach, celiac ganglia, liver and its coronary ligament, inferior vena cava, gallbladder and adrenal glands, with half of the human samples studied presenting phrenic nerve connections with any subdiaphragmatic structure. CONCLUSIONS This review provides the first systematic evidence of subdiaphragmatic phrenic nerve supply and connections. This is of interest to professionals who care for people suffering from neck and shoulder pain, as well as patients with peridiaphragmatic disorders or hiccups. However, there are controversies about the autonomic or sensory nature of this supply.
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Affiliation(s)
- María Pérez-Montalbán
- Universidad de Sevilla. Facultad de Enfermería, Fisioterapia y Podología, Departamento de Fisioterapia, Spain
| | | | - Ángel Oliva-Pascual-Vaca
- Instituto de Biomedicina de Sevilla, IBiS, Departamento de Fisioterapia, Universidad de Sevilla, Spain; Escuela de Osteopatía de Madrid, Madrid, Spain.
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Yang Y, Zhang Y, Dai S, Wang L, Zhang J. Influence of extent of surgical resection on post-hepatectomy shoulder pain: an observational study. Sci Rep 2023; 13:10861. [PMID: 37407697 DOI: 10.1038/s41598-023-38052-6] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/13/2023] [Accepted: 07/02/2023] [Indexed: 07/07/2023] Open
Abstract
Shoulder pain frequently follows hepatectomy. However, the influence of surgical procedures on shoulder pain is unclear. In this observational study, patients who underwent hepatectomy were enrolled in Shanghai Cancer Center. Shoulder pain and surgical pain were assessed using the numeric rating scale 2 days after surgery. The incidence of shoulder pain was the outcome of the cohort study. Nested case-control analyses were further applied. Three hundred and twelve patients were finally enrolled in this study. Nested case-control analysis showed that there were no significant differences in the number of surgical segments between the two groups (P = 0.09). In addition, minor hepatectomy did not reduce the incidence of shoulder pain compared with major hepatectomy (P = 0.37). The drainage volume within 2 days after surgery was significantly more in those patients with shoulder pain (P = 0.017). In open surgery, surgical sites involving the right anterior lobe (OR (95% CI) 2.021 (1.075, 3.802), P = 0.029) and right posterior lobe (OR (95% CI) 2.322 (1.193, 4.522), P = 0.013) were both independent risk factors for shoulder pain. Left shoulder pain also occurred in patients who did not receive left lateral hepatectomy. The preventive phrenic nerve block was not suitable for post-hepatectomy shoulder pain. Stronger preventative intervention should be used in those high-risk patients.
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Affiliation(s)
- Yuecheng Yang
- Department of Anesthesiology, Fudan University Shanghai Cancer Center, No 270, Dong-An Road, Shanghai, 200032, People's Republic of China
| | - Yunkui Zhang
- Department of Anesthesiology, Fudan University Shanghai Cancer Center, No 270, Dong-An Road, Shanghai, 200032, People's Republic of China
| | - ShengLing Dai
- Department of Hepatic Surgery, Fudan University Shanghai Cancer Center, Shanghai, People's Republic of China
| | - Lu Wang
- Department of Hepatic Surgery, Fudan University Shanghai Cancer Center, Shanghai, People's Republic of China
| | - Jun Zhang
- Department of Anesthesiology, Fudan University Shanghai Cancer Center, No 270, Dong-An Road, Shanghai, 200032, People's Republic of China.
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Shalaby M, Arslan O, Mechanic O, Zitek T. Low CERVICAL-2 plane block, a proposed regional anesthetic technique for acute cholecystitis. Am J Emerg Med 2023; 71:69-73. [PMID: 37343341 DOI: 10.1016/j.ajem.2023.06.011] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/20/2023] [Revised: 06/03/2023] [Accepted: 06/05/2023] [Indexed: 06/23/2023] Open
Abstract
INTRODUCTION Acute cholecystitis is a painful inflammatory disease of the gallbladder. The Low Cervical-2 Plane Block is a retrolaminar block that targets the C3, C4, and C5 spinal nerves, which provide sensory innervation to the gallbladder, in order to potentially provide analgesia to patients with pain associated with acute cholecystitis. METHODS In this brief report, a softly embalmed cadaver was injected with a dye mixture bilaterally. RESULTS Subsequent cadaveric dissection revealed spread of the injectate deep to the prevertebral fascia to the C4 lamina on the right side and the C5 lamina on the left side. Also, diffusion of the anesthetic over the ligamenta flava could spread inferiorly and laterally to the spinal nerve roots of C3-C5 and thus potentially target the direct sensory innervation of the gallbladder. CONCLUSION The Low Cervical-2 Plane Block is a potentially effective modality for treating intractable pain from acute cholecystitis. However, further cadaveric injections are needed to confirm the exact extent of spread of anesthetic. Clinical application of the Low Cervical-2 Plane Block in patients with acute cholecystitis is needed to establish the efficacy of this theoretical technique.
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Affiliation(s)
- Michael Shalaby
- Department of Emergency Medicine and Critical Care, Herbert Wertheim College of Medicine at Florida International University, Advanced Emergency Ultrasound, Mount Sinai Medical Center Miami Beach, 4300 Alton Road, Miami Beach, FL 33140, USA.
| | - Orhan Arslan
- Department of Cellular Biology & Pharmacology, Herbert Wertheim College of Medicine at Florida International University, 11200 SW 8th St, Miami, FL 33199, USA.
| | - Oren Mechanic
- Department of Emergency Medicine and Critical Care, Herbert Wertheim College of Medicine at Florida International University, Department of Emergency Medicine, Mount Sinai Medical Center Miami Beach, 4300 Alton Road, Miami Beach, FL 33140, USA.
| | - Tony Zitek
- Department of Emergency Medicine and Critical Care, Herbert Wertheim College of Medicine at Florida International University, Department of Emergency Medicine, Mount Sinai Medical Center Miami Beach, 4300 Alton Road, Miami Beach, FL 33140, USA.
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Yang Y, Zhang Y, Dai SL, Wang L, Zhang J. Incidence and risk factors for acute shoulder pain after hepatectomy: a nested case-control study. BMC Anesthesiol 2022; 22:395. [PMID: 36536284 PMCID: PMC9762078 DOI: 10.1186/s12871-022-01944-7] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/27/2022] [Accepted: 12/14/2022] [Indexed: 12/23/2022] Open
Abstract
BACKGROUND Shoulder pain is commonly reported after hepatic surgery; however, the factors affecting post-hepatectomy shoulder pain remain unclear. This study aimed to determine the incidence and risk factors of shoulder pain after hepatectomy. METHODS This prospective cohort study recruited 218 patients who underwent hepatic resection at our hospital from June to September 2022. Data were obtained from electronic medical records and follow-up assessments on the second postoperative day. All patients denied chronic pain before surgery. In this cohort study, patients were grouped according to the appearance of shoulder pain. Demographic information and perioperative data were compared between the two groups. The relationship between shoulder pain and independent variables was assessed using univariate binary logistic regression analysis. The potential risk factors were analyzed using multivariable binary logistic regression. RESULTS Of the 218 patients enrolled in this cohort study, 91 (41.7%) reported shoulder pain. Patients in the case group were significantly younger than those in the control group (P = 0.001). Epidural anesthesia was used more frequently in the case group (P = 0.012). Patients over 60 years of age showed a lower incidence of shoulder pain than younger patients (P = 0.028). According to multivariable binary logistic regression analysis, advanced age and epidural anesthesia were associated with risk of shoulder pain (advanced age: odds ratio [OR] [95% confidence interval (CI)]: 0.96 [0.94, 0.99], P = 0.002; epidural anesthesia: OR [95% CI]: 2.08 [1.18, 3.69], P = 0.012). CONCLUSIONS The incidence of acute shoulder pain after hepatectomy is 41.7%. The application of epidural anesthesia is an independent risk factor for shoulder pain after hepatectomy, whereas advanced age is a protective factor.
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Affiliation(s)
- Yuecheng Yang
- grid.452404.30000 0004 1808 0942Department of anesthesiology, Fudan University Shanghai Cancer Center, NO 270, Dong-An Road, Shanghai, 200032 People’s Republic of China
| | - Yunkui Zhang
- grid.452404.30000 0004 1808 0942Department of anesthesiology, Fudan University Shanghai Cancer Center, NO 270, Dong-An Road, Shanghai, 200032 People’s Republic of China
| | - Sheng Ling Dai
- grid.452404.30000 0004 1808 0942Department of hepatic surgery, Fudan University Shanghai Cancer Center, Shanghai, People’s Republic of China
| | - Lu Wang
- grid.452404.30000 0004 1808 0942Department of hepatic surgery, Fudan University Shanghai Cancer Center, Shanghai, People’s Republic of China
| | - Jun Zhang
- grid.452404.30000 0004 1808 0942Department of anesthesiology, Fudan University Shanghai Cancer Center, NO 270, Dong-An Road, Shanghai, 200032 People’s Republic of China
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