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Çelikgün B, Gayretli Ö, Gürses İA, Coşkun O, Öztürk A, Kale A. Topographic and morphometric anatomy of the proximal part of the dorsal scapular nerve. Clin Anat 2023; 36:1127-1137. [PMID: 37452523 DOI: 10.1002/ca.24049] [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: 09/08/2022] [Revised: 03/18/2023] [Accepted: 04/10/2023] [Indexed: 07/18/2023]
Abstract
The dorsal scapular nerve (DSN) entrapment neuropathy has recently been recognized as a common cause of circumscapular pain and cases of winged scapula. Course of the nerve is important because the middle scalene muscle is frequently accessed for surgical treatments. Studies in the literature have not focused on the morphometric relationship of the DSN with the scalene muscles and its relationship with the long thoracic nerve (LTN). The neck regions of 13 adult cadavers were dissected bilaterally. The relationship of DSN with scalene muscles and LTN was evaluated. Cervical spinal nerves involved in the formation of the DSN were identified. Three types of DSN were observed based on the cervical spinal nerves from which it originates, five types of DSN from its relationship with the scalene muscles, and two types of DSN from its relationship with the LTN. The distance from where the nerve pierces the scalene muscle to the mastoid process was found to be greater in DSNs originating from C4 and C5 (93.85 ± 4.11 mm, p = 0.033). In DSNs not connected with LTN, the distance from where the nerve pierces the scalene muscle to the superior trunk/C5 (12.74 ± 7.73 mm, p = 0.008) and the length of the nerve within the scalene muscle (14.94 ± 5.5 mm, p = 0.029) were found to be statistically significantly greater. The topographic and morphometric anatomy of the proximal part of the DSN is important, especially for scalene muscles-focused surgical treatments and interscalene nerve blocks. We believe our results may guide clinical approaches and surgery.
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Affiliation(s)
- Beyza Çelikgün
- Department of Anatomy, Faculty of Medicine, Istanbul University, Istanbul, Turkey
- Department of Anatomy, Faculty of Medicine, Institute of Graduate Studies in Health Sciences, Istanbul University, Istanbul, Turkey
- Department of Anatomy, Faculty of Medicine, Istanbul Health and Technology University, Istanbul, Turkey
| | - Özcan Gayretli
- Department of Anatomy, Faculty of Medicine, Istanbul University, Istanbul, Turkey
| | - İlke Ali Gürses
- Department of Anatomy, Faculty of Medicine, Koç University, Istanbul, Turkey
| | - Osman Coşkun
- Department of Anatomy, Faculty of Medicine, Istanbul University, Istanbul, Turkey
| | - Adnan Öztürk
- Department of Anatomy, Faculty of Medicine, Istanbul Health and Technology University, Istanbul, Turkey
| | - Ayşin Kale
- Department of Anatomy, Faculty of Medicine, Istanbul University, Istanbul, Turkey
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Kang R, Ko JS. Recent updates on interscalene brachial plexus block for shoulder surgery. Anesth Pain Med (Seoul) 2023; 18:5-10. [PMID: 36746896 PMCID: PMC9902626 DOI: 10.17085/apm.22254] [Citation(s) in RCA: 4] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/22/2022] [Accepted: 12/20/2022] [Indexed: 01/11/2023] Open
Abstract
Interscalene brachial plexus block (ISBPB) provides optimal analgesia for shoulder surgery. However, several limitations still exist, including the short duration of analgesia, rebound pain, a high incidence of unilateral diaphragmatic paresis, and potential risk of nerve damage, prompting the search for alternative techniques. Many alternatives to ISBPB have been studied to alleviate these concerns, and clinicians should choose an appropriate option based on the patient's condition. In this mini-review, we aimed to present recent updates on ISBPB while discussing our clinical experiences in shoulder surgery.
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Affiliation(s)
| | - Justin Sangwook Ko
- Corresponding author: Justin Sangwook Ko, M.D., Ph.D. Department of Anesthesiology and Pain Medicine, Samsung Medical Center, Sungkyunkwan University School of Medicine, 81 Irwon-ro, Gangnam-gu, Seoul 06351, Korea Tel: 82-2-3410-2454 Fax: 82-2-3410-0361 E-mail:
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Kang BH, Lee DW, Kang S, Yoon JS. Risk assessment of dorsal scapular nerve injury in the medial scapular area associated with upper extremity position: An ultrasonographic study. Muscle Nerve 2023; 67:39-44. [PMID: 36354084 DOI: 10.1002/mus.27750] [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: 05/16/2022] [Revised: 11/01/2022] [Accepted: 11/06/2022] [Indexed: 11/11/2022]
Abstract
INTRODUCTION/AIMS Injuries to the dorsal scapular nerve (DSN) in the interscapular region are relatively uncommon. Physicians may therefore underestimate the risk of damage to the DSN during procedures. The aim of this study was to identify the topographic position of the DSN in the interscapular region and to identify injection positions for the upper extremities that minimize the risk of damage to the DSN during procedures. METHODS The positional relationships between the DSN and scapula were quantified by ultrasonography in 46 healthy volunteers. The distances between the medial scapular line and DSN and the DSN depths from the surface in Zones 1 (the superior angle), 2 (the scapular spine), and 3 (between the scapular spine and inferior angle) were measured in the anatomical and contralateral shoulder touch positions (positions 1 and 2, respectively). RESULTS The DSN was located further away from the medial border of the scapula and closer to the skin in position 2 than in position 1. The horizontal distance of the DSN in Zone 2 differed significantly between the two positions (0.85 ± 0.38 vs 1.23 ± 0.38, P < .001). The results suggest a safe area as just medial to the medial scapular border in Zone 2 in position 2. The safety margin should be considered at least 1.5 cm medial to the medial border of the scapula in Zone 3 in position 1. DISCUSSION Performing invasive procedures in the interscapular region, appropriate individualized positioning may reduce the risk of DSN injury.
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Affiliation(s)
- Byung Heon Kang
- Department of Physical Medicine and Rehabilitation, Korea University Guro Hospital, Seoul, Korea
| | - Dae Wook Lee
- Department of Physical Medicine and Rehabilitation, Korea University Guro Hospital, Seoul, Korea
| | - Seok Kang
- Department of Physical Medicine and Rehabilitation, Korea University Guro Hospital, Seoul, Korea
| | - Joon Shik Yoon
- Department of Physical Medicine and Rehabilitation, Korea University Guro Hospital, Seoul, Korea
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Kumar A, Sinha C, Kumar A, Singh K. Refining the drug injection site during ultrasound-guided interscalene brachial plexus block: root or trunk? Anaesthesiol Intensive Ther 2023; 55:372-373. [PMID: 38282505 PMCID: PMC10801454 DOI: 10.5114/ait.2023.134278] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/15/2023] [Accepted: 04/25/2023] [Indexed: 01/30/2024] Open
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Hernandez N, de Haan JB. Regional Anesthesia for Trauma in the Emergency Department. CURRENT ANESTHESIOLOGY REPORTS 2022. [DOI: 10.1007/s40140-022-00531-3] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/28/2022]
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Marhofer P, Harkanyi A, Hopkins PM. Regional anesthesia for shoulder surgery. Minerva Anestesiol 2022; 88:629-634. [PMID: 35164494 DOI: 10.23736/s0375-9393.22.16295-4] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/08/2022]
Abstract
Regional anaesthesia should be the preferred technique for analgesia in shoulder surgery, which is a frequent procedure in the daily practice of anaesthesiologists. The use of ultrasound guidance enables the visualization of the relevant nerve structures and the adjacent anatomical details. Low volumes of local anaesthetics reduce the incidence of inadvertent blockade of the phrenic nerve with subsequent respiratory impairment. The additional administration of dexmedetomidine to local anaesthetics prolonges the duration of analgesia with a minimal increased incidence of haemodynamic side effects. An optimal workflow is associated with economical advantages due to an improved use of operation rooms. Attention have to be paid regarding intraoperative hypotension, cerebral hypoperfusion and complications due to positioning.
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Affiliation(s)
- Peter Marhofer
- Department of Anaesthesiology and Intensive Care Medicine, Orthopaedic Hospital Speising, Vienna, Austria - .,Department of Anaesthesiology, General Intensive Care Medicine and Pain Therapy, Medical University of Vienna, Vienna, Austria -
| | - Arpad Harkanyi
- Department of Anaesthesiology and Intensive Care Medicine, Orthopaedic Hospital Speising, Vienna, Austria
| | - Phil M Hopkins
- Institute of Medical Research at St James's, University of Leeds, Leeds, UK
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Kang S, Jeong HM, Kim BS, Yoon JS. Risk Analysis of Needle Injury to the Long Thoracic Nerve during Ultrasound-Guided C7 Selective Nerve Root Block. MEDICINA (KAUNAS, LITHUANIA) 2021; 57:635. [PMID: 34205371 PMCID: PMC8235341 DOI: 10.3390/medicina57060635] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 05/06/2021] [Revised: 06/17/2021] [Accepted: 06/17/2021] [Indexed: 11/17/2022]
Abstract
Background and Objectives: Ultrasound (US)-guided cervical selective nerve root block (SNRB) is a widely used treatment for upper limb radicular pain. The long thoracic nerve (LTN) passes through the middle scalene muscle (MSM) at the C7 level. The needle trajectory of US-guided C7 SNRB pierces the MSM, therefore indicating a high probability of injury to the LTN. We aimed to identify the LTN and to investigate the risk of needle injury to the nerve during US-guided C7 SNRB. Materials and Methods: This retrospective observational study included 30 patients who underwent US-guided SNRB at the C7 level in a university hospital. We measured the maximal cross-sectional diameter (MCSD) of the LTN and cross-sectional area (CSA) of the C7 nerve root and assessed the injury risk of LTN during US-guided C7 SNRB by simulating the trajectory of the needle in the ultrasound image. Results: The LTN was detectable in all the cases, located inside and outside the MSM in 19 (63.3%) and 11 (36.7%) of cases, respectively. The LTN's mean MCSD was 2.10 mm (SD 0.13), and the C7 root's CSA was 10.78 mm2 (SD 1.05). The LTN location was within the simulated risk zone in 86.7% (26/30) of cases. Conclusion: Our findings suggest a high potential for LTN injury during US-guided C7 SNRB. The clear visualization of LTNs in the US images implies that US guidance may help avoid nerve damage and make the procedure safer. When performing US-guided C7 SNRB, physicians should take into consideration the location of the LTN.
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Affiliation(s)
- Seok Kang
- Department of Rehabilitation Medicine, Korea University Guro Hospital, Seoul 08308, Korea; (S.K.); (H.-M.J.)
| | - Ha-Mok Jeong
- Department of Rehabilitation Medicine, Korea University Guro Hospital, Seoul 08308, Korea; (S.K.); (H.-M.J.)
| | - Beom-Suk Kim
- Uijeongbu Eulji Medical Center, Department of Rehabilitation Medicine, Uijeongbu 11759, Korea;
| | - Joon-Shik Yoon
- Department of Rehabilitation Medicine, Korea University Guro Hospital, Seoul 08308, Korea; (S.K.); (H.-M.J.)
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Silkjær Bak S, Johnsen B, Fuglsang-Frederiksen A, Døssing K, Qerama E. Neuromuscular ultrasound of the scapular stabilisers in healthy subjects. Clin Neurophysiol Pract 2021; 6:72-80. [PMID: 33732970 PMCID: PMC7937536 DOI: 10.1016/j.cnp.2021.01.003] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/13/2020] [Revised: 12/29/2020] [Accepted: 01/24/2021] [Indexed: 11/17/2022] Open
Abstract
HRUS can be used to visualise the muscles stabilizing the scapula and their corresponding nerves. We found acceptable intra- and inter-examiner agreements. We present HRUS normative data using regression-based prediction formulas. To our knowledge, we present the first-time normative data of diameter of the dorsal scapular nerve.
Objectives To obtain normative high-resolution ultrasound (HRUS) data for thickness of the serratus anterior, the trapezius and the rhomboid major muscles and diameter of their corresponding nerves, the long thoracic, the spinal accessory and the dorsal scapular nerve. Moreover, we aimed to examine intra- and inter-examiner agreement of the HRUS measurements. Methods We included 41 healthy subjects. Muscle thickness and nerve diameter were measured bilaterally, resulting in 82 ultrasound measurements for each structure. Normative data were calculated using regression equations for the lower limit of muscle thickness and upper limit of nerve diameter, taking into account various variables. For intra- and inter-examiner agreement, ten subjects underwent two extra ultrasound examinations and Bland-Altman plots were calculated. Results This normative data set showed significant correlations between decreasing muscle thickness with increasing age and height and increasing muscle thickness with increasing weight and with male sex. Muscle thickness was larger on the dominant side compared to the non-dominant side for the trapezius and rhomboid muscles, whereas the opposite was found for the serratus anterior muscle. For all nerves, significant correlations were found between decreasing nerve diameter with increasing age and height. Intra-examiner agreement was acceptable in all sites. Inter-examiner agreement was acceptable for all sites but one site for the serratus anterior muscle and long thoracic nerve, and not acceptable for five out of six sites for the trapezius muscle. Conclusion This study provides HRUS normative data and intra- and inter-examiner agreement data for muscle thickness and nerve diameter for the muscles stabilizing the scapulae and their corresponding nerves. Significance The normative HRUS data reported may be useful in future studies investigating neuromuscular disorders.
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Affiliation(s)
- Sara Silkjær Bak
- Department of Clinical Neurophysiology, Aarhus University Hospital, Palle Juul-Jensens Boulevard 16, Plan 2, J209, DK-8200 Aarhus N, Denmark
| | - Birger Johnsen
- Department of Clinical Neurophysiology, Aarhus University Hospital, Palle Juul-Jensens Boulevard 16, Plan 2, J209, DK-8200 Aarhus N, Denmark.,Department of Clinical Medicine, Aarhus University Hospital, Palle Juul-Jensens Boulevard 82, Incuba/Skejby, Building 2, DK-8200 Aarhus N, Denmark
| | - Anders Fuglsang-Frederiksen
- Department of Clinical Neurophysiology, Aarhus University Hospital, Palle Juul-Jensens Boulevard 16, Plan 2, J209, DK-8200 Aarhus N, Denmark.,Department of Clinical Medicine, Aarhus University Hospital, Palle Juul-Jensens Boulevard 82, Incuba/Skejby, Building 2, DK-8200 Aarhus N, Denmark
| | - Kaj Døssing
- Department of Orthopaedics, Viborg Regional Hospital, Heibergs Alle 4F Indgang F, Etage 3, 8800 Viborg, Denmark
| | - Erisela Qerama
- Department of Clinical Neurophysiology, Aarhus University Hospital, Palle Juul-Jensens Boulevard 16, Plan 2, J209, DK-8200 Aarhus N, Denmark.,Department of Clinical Medicine, Aarhus University Hospital, Palle Juul-Jensens Boulevard 82, Incuba/Skejby, Building 2, DK-8200 Aarhus N, Denmark
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Feigl GC, Litz RJ, Marhofer P. Anatomy of the brachial plexus and its implications for daily clinical practice: regional anesthesia is applied anatomy. Reg Anesth Pain Med 2020; 45:620-627. [DOI: 10.1136/rapm-2020-101435] [Citation(s) in RCA: 21] [Impact Index Per Article: 5.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/02/2020] [Revised: 05/01/2020] [Accepted: 05/04/2020] [Indexed: 12/29/2022]
Abstract
Safety and effectiveness are mandatory requirements for any technique of regional anesthesia and can only be met by clinicians who appropriately understand all relevant anatomical details. Anatomical texts written for anesthetists may oversimplify the facts, presumably in an effort to reconcile extreme complexity with a need to educate as many users as possible. When it comes to techniques as common as upper-extremity blocks, the need for customized anatomical literature is even greater, particularly because the complex anatomy of the brachial plexus has never been described for anesthetists with a focus placed on regional anesthesia. The authors have undertaken to close this gap by compiling a structured overview that is clinically oriented and tailored to the needs of regional anesthesia. They describe the anatomy of the brachial plexus (ventral rami, trunks, divisions, cords, and nerves) in relation to the topographical regions used for access (interscalene gap, posterior triangle of the neck, infraclavicular fossa, and axillary fossa) and discuss the (interscalene, supraclavicular, infraclavicular, and axillary) block procedures associated with these access regions. They indicate allowances to be made for anatomical variations and the topography of fascial anatomy, give recommendations for ultrasound imaging and needle guidance, and explain the risks of excessive volumes and misdirected spreading of local anesthetics in various anatomical contexts. It is hoped that clinicians will find this article to be a useful reference for decision-making, enabling them to select the most appropriate regional anesthetic technique in any given situation, and to correctly judge the risks involved, whenever they prepare patients for a specific upper-limb surgical procedure.
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Cho HR, Cho BH, Kang KN, Kim YU. Optimal Cut-Off Value of the Coracohumeral Ligament Area as a Morphological Parameter to Confirm Frozen Shoulder. J Korean Med Sci 2020; 35:e99. [PMID: 32301291 PMCID: PMC7167408 DOI: 10.3346/jkms.2020.35.e99] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/16/2019] [Accepted: 02/17/2020] [Indexed: 01/04/2023] Open
Abstract
BACKGROUND Thickened coracohumeral ligament (CHL) is one of the important morphological changes of frozen shoulder (FS). Previous research reported that coracohumeral ligament thickness (CHLT) is correlated with anterior glenohumeral instability, rotator interval and eventually FS. However, thickness may change depending on the cutting angle, and measurement point. To reduce measurement mistakes, we devised a new imaging criteria, called the coracohumeral ligament area (CHLA). METHODS CHL data were collected and analyzed from 52 patients with FS, and from 51 control subjects (no evidence of FS). Shoulder magnetic resonance imaging was performed in all subjects. We investigated the CHLT and CHLA at the maximal thickened view of the CHL using our picture archiving and communications system. The CHLA was measured as the whole area of the CHL including the most hypertrophied part of the MR images on the oblique sagittal plane. The CHLT was measured at the thickest point of the CHL. RESULTS The average CHLA was 40.88 ± 12.53 mm² in the control group and 67.47 ± 19.88 mm² in the FS group. The mean CHLT was 2.84 ± 0.67 mm in the control group and 4.01 ± 1.11 mm in the FS group. FS patients had significantly higher CHLA (P < 0.01) and CHLT (P < 0.01) than the control group. The receiver operator characteristic analysis showed that the most suitable cut-off score of the CHLA was 50.01 mm², with 76.9% sensitivity, 76.5% specificity, and area under the curve (AUC) of 0.87. The most suitable cut-off value of the CHLT was 3.30 mm, with 71.2% sensitivity, 70.6% specificity, and AUC of 0.81. CONCLUSION The significantly positive correlation between the CHLA, CHLT and FS was found. We also demonstrate that the CHLA has statistically equivalent power to CHLT. Thus, for diagnosis of FS, the treating physician can refer to CHLA as well as CHLT.
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Affiliation(s)
- Hyung Rae Cho
- Department of Anesthesiology and Pain Medicine, Myongji Hospital, Hanyang University College of Medicine, Goyang, Korea
| | - Byong Hyon Cho
- Department of Anesthesiology and Pain Medicine, Myongji Hospital, Hanyang University College of Medicine, Goyang, Korea
| | - Keum Nae Kang
- Department of Anesthesiology and Pain Medicine, National Police Hospital, Seoul, Korea
| | - Young Uk Kim
- Department of Anesthesiology and Pain Medicine, Catholic Kwandong University, College of Medicine, International St. Mary's Hospital, Incheon, Korea.
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Superior Trunk Block Provides Noninferior Analgesia Compared with Interscalene Brachial Plexus Block in Arthroscopic Shoulder Surgery. Anesthesiology 2019; 131:1316-1326. [DOI: 10.1097/aln.0000000000002919] [Citation(s) in RCA: 41] [Impact Index Per Article: 8.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
Abstract
Editor’s Perspective
What We Already Know about This Topic
What This Article Tells Us That Is New
Background
Interscalene brachial plexus block of the C5–C6 roots provides highly effective postoperative analgesia after shoulder surgery but usually results in hemidiaphragmatic paresis. Injection around the superior trunk of the brachial plexus is an alternative technique that may reduce this risk. The authors hypothesized that the superior trunk block would provide noninferior postoperative analgesia compared with the interscalene block and reduce hemidiaphragmatic paresis.
Methods
Eighty patients undergoing arthroscopic shoulder surgery were randomized to receive a preoperative injection of 15 ml of 0.5% ropivacaine and 5 μg · ml−1 epinephrine around either (1) the C5–C6 nerve roots (interscalene block group) or (2) the superior trunk (superior trunk block group). The primary outcome was pain intensity 24 h after surgery measured on an 11-point numerical rating score; the prespecified noninferiority limit was 1. Diaphragmatic function was assessed using both ultrasonographic measurement of excursion and incentive spirometry by a blinded investigator before and 30 min after block completion.
Results
Seventy-eight patients completed the study. The pain score 24 h postoperatively (means ± SDs) was 1.4 ± 1.0 versus 1.2 ± 1.0 in the superior trunk block (n = 38) and interscalene block (n = 40) groups, respectively. The mean difference in pain scores was 0.1 (95% CI, −0.3 to 0.6), and the upper limit of the 95% CI was lower than the prespecified noninferiority limit. Analgesic requirements and all other pain measurements were similar between groups. Hemidiaphragmatic paresis was observed in 97.5% of the interscalene block group versus 76.3% of the superior trunk block group (P = 0.006); paresis was complete in 72.5% versus 5.3% of the patients, respectively. The decrease in spirometry values from baseline was significantly greater in the interscalene block group.
Conclusions
The superior trunk block provided noninferior analgesia compared with interscalene brachial plexus block for up to 24 h after arthroscopic shoulder surgery and resulted in significantly less hemidiaphragmatic paresis.
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Cho H, Kang S, Won HS, Yang M, Kim YD. New insights into pathways of the dorsal scapular nerve and artery for selective dorsal scapular nerve blockade. Korean J Pain 2019; 32:307-312. [PMID: 31569924 PMCID: PMC6813903 DOI: 10.3344/kjp.2019.32.4.307] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/28/2019] [Revised: 08/02/2019] [Accepted: 08/23/2019] [Indexed: 11/05/2022] Open
Abstract
Background The aim of this study was to clarify the topographical relationships between the dorsal scapular nerve (DSN) and the dorsal scapular artery (DSA) in the interscapular region to identify safe and convenient injection points related to DSN blockade. Methods Thirty shoulders of embalmed Korean cadavers and 50 live subjects were used for dissection and ultrasound (US) analysis. Results The running patterns of the DSA and DSN in the interscapular region were classified into 3 types. Type I was defined as nerves that were medial to the artery and parallel without changing location (80.0% of specimens). In type II (13.3%), the nerve and artery traversed one another only one time over their entire length. In type III (6.7%), the nerve and artery traversed one another, resembling a twist. Above the level of the scapular spine, the nerve was always medial to the artery. Below the scapular spine, the number of arteries was obviously decreased. Most of the arteries were lateral to the medial border of the scapula, except at the level of the superior angle of the scapula artery (SA). The positional tendency of the DSN toward the medial or lateral sides from the medial border of the scapula was similar. In US imaging of live subjects, the DSA was most observed at the level of the SA (94.0%). Conclusions Results of this study enhance the current knowledge regarding the pathway of the DSN and DSA and provide helpful information for selective diagnostic nerve blocks in the interscapular region.
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Affiliation(s)
- Hyunho Cho
- Department of Anesthesiology and Pain Medicine, Wonkwang University Hospital, Wonkwang University School of Medicine, Iksan, Korea.,Jesaeng-Euise Clinical Anatomy Center, Wonkwang University School of Medicine, Iksan, Korea
| | - Seungwoo Kang
- Department of Anatomy, Wonkwang University School of Medicine, Iksan, Korea
| | - Hyung-Sun Won
- Jesaeng-Euise Clinical Anatomy Center, Wonkwang University School of Medicine, Iksan, Korea.,Department of Anatomy, Wonkwang University School of Medicine, Iksan, Korea
| | - Miyoung Yang
- Jesaeng-Euise Clinical Anatomy Center, Wonkwang University School of Medicine, Iksan, Korea.,Department of Anatomy, Wonkwang University School of Medicine, Iksan, Korea
| | - Yeon-Dong Kim
- Department of Anesthesiology and Pain Medicine, Wonkwang University Hospital, Wonkwang University School of Medicine, Iksan, Korea.,Jesaeng-Euise Clinical Anatomy Center, Wonkwang University School of Medicine, Iksan, Korea.,Wonkwang Institute of Science, Wonkwang University School of Medicine, Iksan, Korea
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Value of Anterior Band of the Inferior Glenohumeral Ligament Area as a Morphological Parameter of Adhesive Capsulitis. Pain Res Manag 2019; 2019:9301970. [PMID: 31205575 PMCID: PMC6530218 DOI: 10.1155/2019/9301970] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/22/2018] [Revised: 03/18/2019] [Accepted: 03/28/2019] [Indexed: 11/25/2022]
Abstract
Objective Thickened inferior glenohumeral ligament (IGHL) is considered as one of the major morphological parameters of adhesive capsulitis (AC). Previous studies reported that the anterior band of inferior glenohumeral ligament thickness (aIGHLT) is correlated with shoulder capsular contracture, luxatio erecta humeri, and AC. However, the thickness varies from the measured angle. To reduce this measurement error, we devised a new morphological parameter, called the anterior band of inferior glenohumeral ligament area (aIGHLA). Methods The aIGHL samples were collected from 54 patients with AC and from 50 control subjects who underwent shoulder magnetic resonance imaging (MRI) without any evidence of AC. Coronal T2-weighted MRI images were obtained at the shoulder level from each patient. We measured the aIGHLA and aIGHLT at the maximal view of the IGHL in the coronal plane using our picture archiving and communication system. The aIGHLA was measured at the whole cross-sectional area of the IGHL in the most hypertrophied segment of the coronal MR images. The aIGHLT was measured at the thickest point of the IGHL. Results The average aIGHLA was 55.58 ± 14.16 mm2 in the control group and 83.71 ± 28.45 mm2 in the AC group. The average aIGHLT was 3.47 ± 0.99 mm in the control group and 4.52 ± 1.02 mm in the AC group. AC patients showed significantly greater aIGHLA (p < 0.001) and aIGHLT (p < 0.001) than control subjects. Receiver operating characteristic (ROC) curve analysis showed that the optimal cut-off score of the aIGHLA was 63.37 mm2, with 79.6% sensitivity, 80.0% specificity, and AUC of 0.84 (95% CI, 0.76–0.92). The optimal cut-off point of the IGHLT was 3.81 mm, with 74.1% sensitivity, 74.0% specificity, and AUC of 0.77 (95% CI, 0.68–0.86). Conclusions Although the aIGHLA and aIGHLT were both significantly associated with AC, the aIGHLA was a more sensitive diagnostic parameter.
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Tetsu S, Terayama H, Qu N, Yamazaki H, Sakamoto R, Tanaka O, Suyama K, Takenaka M, Suzuki T, Sakabe K. Anatomical variants of dorsal scapular nerve in relation to the middle scalene muscle in Japanese population. Medicine (Baltimore) 2018; 97:e13349. [PMID: 30461656 PMCID: PMC6392864 DOI: 10.1097/md.0000000000013349] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/26/2022] Open
Abstract
Dorsal scapular nerve (DSN) block is often performed in Japanese pain clinics to treat neck pain and katakori (a unique symptom in Japanese population characterized by myofascial pain syndromes such as shoulder girdle pain). However, to the best of our knowledge, there are only a few studies regarding anatomical variations in DSN paths around the middle scalene muscle (MSM) in Japanese population. Thus, we conducted a cadaveric study to examine anatomical variations in DSN paths around the MSM in Japanese population.DSN anatomies of 70 adult Japanese cadavers used for research and gross anatomy practice at the Tokai University School of Medicine between 2015 and 2016 were examined.In all cadavers, DSNs originated from the brachial plexus (BP) and innervated the rhomboid major, rhomboid minor, and levator scapulae muscles via the MSM. Two types of DSN paths were observed: piercing-type (piercing the MSM) and anterior-type (running in front of the MSM). We surveyed all 140 sides in 70 Japanese cadavers; of these, 95 sides had piercing-type and 45 had anterior-type paths. Of the 70 cadavers, 42 had piercing-type and 17 had anterior-type paths on both the sides. In 9 cadavers, the left and right sides had piercing-type and anterior-type paths, respectively. In the other 2 cadavers, the right and left sides had piercing-type and anterior-type paths, respectively.We found 2 distinct anatomical variants for DSN paths around the MSM in this Japanese cohort. Our results suggest that the rate of anterior-type DSN path is higher in Japanese population. Therefore, it is necessary to maintain caution while injecting anesthetic agents during a DSN block and the type of DSN should be considered.
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Affiliation(s)
| | | | | | | | | | | | | | - Motoyasu Takenaka
- Department of Palliative medicine, Tokai University School of Medicine 143, Shimokasuya, Isehara-shi, Kanagawa, Japan
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15
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Lee DG, Chang MC. Dorsal scapular nerve injury after trigger point injection into the rhomboid major muscle: A case report. J Back Musculoskelet Rehabil 2018; 31:211-214. [PMID: 28854498 DOI: 10.3233/bmr-169740] [Citation(s) in RCA: 13] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/04/2023]
Abstract
BACKGROUND AND OBJECTIVE We report the case of a patient who presented with right dorsal scapular neuropathy after a trigger point injection into the right rhomboid major muscle. Through a nerve conduction study and electromyography, we demonstrated dorsal scapular nerve injury in this patient. CASE REPORT A 38-year-old man complained that his right shoulder functioned less optimally during push-up exercises after a trigger point injection 4 weeks prior. Physical examination revealed mildly reduced right shoulder retractor muscle strength compared with the left side. We performed a nerve conduction velocity test and electromyography 5 weeks after the injection. The compound muscle action potential of the right dorsal scapular nerve showed low amplitude (left vs. right side: 5.2 vs. 1.6 mV) and delayed latency (left vs. right side: 4.9 vs. 6.8 ms). Positive sharp wave (1+) and mildly reduced recruitment were seen on electromyography of the rhomboid major muscle. The findings of the nerve conduction velocity test and electromyography indicated partial right dorsal scapular neuropathy. The nerve injury seemed to have been caused by the needle inserted during trigger point injection. CONCLUSION Clinicians should pay attention to the occurrence of dorsal scapular nerve injury when performing trigger point injection into the rhomboid muscle.
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16
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Dengler NF, Antoniadis G, Grolik B, Wirtz CR, König R, Pedro MT. Mechanisms, Treatment, and Patient Outcome of Iatrogenic Injury to the Brachial Plexus-A Retrospective Single-Center Study. World Neurosurg 2017; 107:868-876. [PMID: 28847555 DOI: 10.1016/j.wneu.2017.08.119] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/23/2017] [Revised: 08/16/2017] [Accepted: 08/17/2017] [Indexed: 11/20/2022]
Abstract
BACKGROUND Injury to the brachial plexus is a devastating condition, with severe impairment of upper extremity function resulting in distinct disability. There are no systematic reports on epidemiology, causative mechanisms, treatment strategies. or outcomes of iatrogenic brachial plexus injury (iBPI). METHODS We screened all cases of iatrogenic nerve injuries recorded between 2007 and 2017 at a single specialized institution. Mechanism of iBPI, type of previous causative intervention, location and type of the lesion as well as the type of revision surgery and functional patient outcome were analyzed. RESULTS We identified 14 cases of iBPI, which all presented with significant impairment of upper extremity motor function (at least 1 muscle Medical Research Council grade 0). Neuropathic pain was present in most patients (11/14). Orthopedic shoulder procedures such as rotator cuff fixation, arthroplasty, and repositioning of a clavicle fracture accounted for iBPI in 7 of 14 patients. Other reasons for iBPI were resection or biopsy of a peripheral nerve sheath tumor in 3 patients or lymph node situated at the cervicomediastinal area in 2 patients. Mechanisms also included transaxillary rib resection in one and sternotomy in another patient. The treatment of iBPI was conducted according to each individual's needs and included neurolysis in 4, nerve grafting in 9, and nerve transfers in 1 patient. We found improved symptoms after treatment in most patients (11/14). CONCLUSIONS Most common causes for iBPI were shoulder surgery and resection or biopsy of peripheral nerve sheath tumor and lymph nodes. Early referral to specialized peripheral nerve centers may help to improve functional patient outcome.
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Affiliation(s)
| | - Gregor Antoniadis
- Peripheral Nerve Surgery Unit, Department of Neurosurgery, Universitätsklinik Ulm am Bezirkskrankenhaus Günzburg, Günzburg, Germany
| | - Brigitta Grolik
- Peripheral Nerve Surgery Unit, Department of Neurosurgery, Universitätsklinik Ulm am Bezirkskrankenhaus Günzburg, Günzburg, Germany
| | - Christian Rainer Wirtz
- Peripheral Nerve Surgery Unit, Department of Neurosurgery, Universitätsklinik Ulm am Bezirkskrankenhaus Günzburg, Günzburg, Germany
| | - Ralph König
- Peripheral Nerve Surgery Unit, Department of Neurosurgery, Universitätsklinik Ulm am Bezirkskrankenhaus Günzburg, Günzburg, Germany
| | - Maria Teresa Pedro
- Peripheral Nerve Surgery Unit, Department of Neurosurgery, Universitätsklinik Ulm am Bezirkskrankenhaus Günzburg, Günzburg, Germany
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17
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Dorsal scapular and long thoracic nerves during ultrasound-guided interscalene brachial plexus block. Asian J Anesthesiol 2017; 55:26-27. [PMID: 28797499 DOI: 10.1016/j.aja.2017.07.001] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/29/2016] [Revised: 11/28/2016] [Accepted: 11/29/2016] [Indexed: 11/20/2022]
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18
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Kim SY, Cheon JH, Seo WJ, Yang GY, Choi YM, Kim KH. A pictorial review of signature patterns living in musculoskeletal ultrasonography. Korean J Pain 2016; 29:217-228. [PMID: 27738500 PMCID: PMC5061638 DOI: 10.3344/kjp.2016.29.4.217] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/19/2016] [Accepted: 09/23/2016] [Indexed: 11/05/2022] Open
Abstract
The musculoskeletal system is mainly composed of the bones, muscles, tendons, and ligaments, in addition to nerves and blood vessels. The greatest difficulty in an ultrasonographic freeze-frame created by the examiner is recognition of the targeted structures without indicators, since an elephant's trunk may not be easily distinguished from its leg. It is not difficult to find descriptive ultrasonographic terms used for educational purposes, which help in distinguishing features of these structures either in a normal or abnormal anatomic condition. However, the terms sometimes create confusion when describing common objects, for example, in Western countries, pears have a triangular shape, but in Asia they are round. Skilled experts in musculoskeletal ultrasound have tried to express certain distinguishing features of anatomic landmarks using terms taken from everyday objects which may be reminiscent of that particular feature. This pictorial review introduces known signature patterns of distinguishing features in musculoskeletal ultrasound in a normal or abnormal condition, and may stir the beginners' interest to play a treasure-hunt game among unfamiliar images within a boundless ocean.
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Affiliation(s)
- Su Young Kim
- Department of Anesthesia and Pain Medicine, School of Medicine, Pusan National University, Yangsan, Korea
| | - Ji Hyun Cheon
- Department of Anesthesia and Pain Medicine, School of Medicine, Pusan National University, Yangsan, Korea
| | - Won Jun Seo
- Department of Anesthesia and Pain Medicine, School of Medicine, Pusan National University, Yangsan, Korea
| | - Geun Young Yang
- Department of Anesthesia and Pain Medicine, School of Medicine, Pusan National University, Yangsan, Korea
| | - Yun Mi Choi
- Department of Anesthesia and Pain Medicine, School of Medicine, Pusan National University, Yangsan, Korea
| | - Kyung Hoon Kim
- Department of Anesthesia and Pain Medicine, School of Medicine, Pusan National University, Yangsan, Korea
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