Anterior Ankle Arthroscopy: Advantage of a Preoperative Ultrasound Mapping to Prevent Neurovascular Complications

PURPOSE

The aim of this study is to verify the usefulness of ultrasound-assisted mapping of the vascular and neurological structures in the anterior compartment of the ankle just before an anterior arthroscopic procedure to reduce these kinds of complications.

METHODS

Various complications can be present in anterior arthroscopy of the ankle. The structures most prone to iatrogenic damage are vessels and nerves. They are macroscopically visible and palpable in a little more than 50% of cases, but arterial ramifications are not visible because they are located deeper.

RESULTS

The authors have investigated how to reduce potential iatrogenic damage to the complex and variable neuro-vascular network of the anterior aspect of the ankle. They have completed the classic routine marking of the bony and tendinous structures with an ultrasound mapping of the neurovascular structures.

CONCLUSIONS

The authors concluded that ultrasound-assisted mapping is a non-invasive, fast, and safe procedure that can help to reduce potential iatrogenic damage when performing anterior arthroscopic surgery.

Sonographic Guidance for Caudal Epidural Steroid Injection: A Diagnostic Tool

Ultrasound (US)-guided caudal epidural injection is a method of drug administration into the epidural space through the sacral hiatus for both chronic pain management and perioperative analgesia. Here, we describe the usefulness of US sacral examination performed before a caudal epidural injection procedure, in which the results revealed a sacrococcygeal ligament ossification prompting us to avoid its puncture by placing the Thouy needle in the appropriate direction. This prevented an unwanted calcification rupture with a possible drag of material into the sacral canal. US has already been used as a diagnostic tool in caudal epidural injection, mainly to detect the agenesis of sacral hiatus or to measure its diameter. Our case underlines the possibility of finding ossification and calcification using US, which can make the injection difficult or impossible and be a side effect if not recognised.

Cadaveric Model Simulations for Training in Ultrasound-Guided Percutaneous Placement of a Novel Peripheral Nerve Stimulation Electrode

Peripheral nerve stimulation (PNS) electrodes are used to treat intractable painful conditions involving peripheral nerves. Methods for performing PNS continue to evolve, from open surgical to minimally invasive placement of electrodes. A PNS system consisting of subcutaneously implanted leads with an integrated anchor and electrodes, and an external pulse generator to produce peripheral neuromodulation, is now available for use in the clinical setting. This novel system allows either surgical or percutaneous lead positioning, and avoids the use of long leads or extensions crossing the joints, which are exposed to mechanical stress and damage. To identify methods for successfully inserting these electrodes, we investigated if a cadaver model could be an effective educational tool for teaching PNS electrode placement using ultrasound guidance. Six cadavers were studied in an attempt to find an ideal approach for ultrasound-guided electrode placement into the upper and lower extremities and cervical spine, and to describe the unique anatomy of the peripheral nerves relative to percutaneous stimulation-electrode placement. The use of cadaveric model simulations offers opportunities to practice percutaneous placement of PNS electrodes under stress-free conditions without patient discomfort, to acquire skill and confidence in performing these surgical approaches. Ultrasound-guided percutaneous placement of PNS electrodes should be learned in a simulation laboratory before such placement is performed in actual patients.

Pain reduction induced by tapentadol in patients with musculoskeletal chronic pain fosters better sleep quality

Background

Poor sleep may predict the increase and intensification of pain over time with increased insomnia symptoms being both a predictor and an indicator of worse pain outcomes and physical functioning status over time. However, the impact of different analgesic therapies on quality of life, functional recovery and sleep has been poorly assessed to date, whereas these evaluations may greatly help clinicians in the selection of treatment when dealing with patients with chronic pain (CP).

Methods

To explore whether tapentadol-induced pain relief may drive improved sleep quality, we carried out a pooled analysis of real-world data collected from 487 patients with CP (mean age, 68.3 years; 57.7% women) suffering from a wide range of chronic musculoskeletal pain conditions and treated with tapentadol.

Results

Following tapentadol treatment, patients experienced an 80% reduction in the frequency of very disturbed sleep as well as a 50% reduction in the predominant sleep complaint reported by patients with CP - that is, nocturnal awakenings. A significantly greater proportion of patients reported good/restful sleep at the end of the study period compared to baseline (72.4% versus 25.3%; p<0.01). This benefit was observed regardless of the clinical setting, treatment duration, posology or patient age and was associated with a higher proportion of patients reporting an improved global health status and good tolerability.

Conclusion

The reduction in pain intensity provided by tapentadol fosters sleep quality and favours a better quality of life. Therefore, our findings provide the rationale for addressing sleep quality as a relevant outcome, complementary to pain relief in CP management.

Erector spinae plane block and rhomboid intercostal block for the treatment of post-mastectomy pain syndrome

Post-mastectomy pain syndrome (PMPS) can have multiple pain generators, including neuropathic pain and myofascial pain syndrome (MPS). Erector spinae plane (ESP) block and rhomboid intercostal block (RIB) have been used to provide anesthesia of the thorax and also for some chronic pain conditions. We describe a 43-year-old man suffering from right PMPS after right mastectomy, full axillary, and mammary lymph node dissection. We treated her with ESP blocks and RIB to reduce neuralgia and MPS: Neuropathic pain disappeared and the patient experienced only slight residual pain. The result was maintained 3 months later. This report suggests that ESP block and RIB with local anesthetic and corticosteroids with might be useful to treat a PMPS.

Prolotherapy: Regenerative Medicine for Lateral Epicondylitis

Lateral epicondylitis (LE) is a degenerative disease of the tendons, spurred by repetitive microtrauma leading to an attempt by the body to heal by upregulating local angiogenesis and fibroblast proliferation. Prolotherapy (PT) is the injection of dextrose around the injured tissues to stimulate their spontaneous regeneration. Herein, we have described a case of lateral epicondylitis, diagnosed with clinical and ultrasound (US) examination, where local steroid injections provided relief only for a limited time. We treated the patient with US-guided PT, following which the pain disappeared and the tendon was restored.

Ultrasound-guided erector spinae block for post-thoracotomy pain syndrome in video-assisted thoracic surgery

This article describes our experience with 5 patients with post-thoracotomy pain syndrome after video-assisted thoracoscopic lobectomies, treated with weekly erector spinae plane block. We injected corticosteroid and local anesthetic. At the end of the treatment period, pain scores decreased significantly. Our experience suggests that erector spinae plane block may have a role in the treatment of post-thoracoscopy pain syndrome.

Ultrasound Guided Transversus Thoracic Plane block, Parasternal block and fascial planes hydrodissection for internal mammary post thoracotomy pain syndrome

INTRODUCTION

Pectoral Nerves Block (PECS) and Serratus Plane Block (SPB) have been used to treat persistent post-surgical pain after breast and thoracic surgery; however, they cannot block the internal mammary region, so a residual pain may occur in that region. Parasternal block (PSB) and Thoracic Transversus Plane Block (TTP) anaesthetize the anterior branches of T2-6 intercostal nerves thus they can provide analgesia to the internal mammary region.

METHODS

We describe a 60-year-old man suffering from right post-thoracotomy pain syndrome with residual pain located in the internal mammary region after a successful treatment with PECS and SPB. We performed a PSB and TTP and hydrodissection of fascial planes with triamcinolone and Ropivacaine.

RESULTS

Pain disappeared and the result was maintained 3 months later.

DISCUSSION

This report suggests that PSB and TTP with local anaesthetic and corticosteroid with hydrodissection of fascial planes might be useful to treat a post thoracotomy pain syndrome located in the internal mammary region.

SIGNIFICANCE

The use of Transversus Thoracic Plane and Parasternal Blocks and fascial planes hydrodissection as a novel therapeutic approach to treat a residual post thoracotomy pain syndrome even when already treated with Pectoral Nerves Block and Serratus Plane Block.