Femoral Nerve Blocks versus Standard Pain Control for Hip Fractures: A Retrospective Comparative Analysis

Introduction

Pain control for hip fractures is often achieved via intravenous opioids. However, opioids can have dangerous adverse effects, including respiratory depression and delirium. Peripheral nerve blockade is an alternative option for pain control, which reduces the need for opioid analgesia. The purpose of this study was to compare the use of femoral nerve blocks versus standard pain control for patients with hip fractures.

Methods

This retrospective study included adult patients presenting to the emergency department (ED) with isolated hip fractures between April 2021 and September 2022. The intervention group included all patients who received a femoral nerve block during this time. An equivalent number of patients who received standard pain control during that period were randomly selected to represent the control group. The primary outcome was pre-operative opioid requirement, assessed by morphine milligram equivalents (MME).

Results

During the study period, 90 patients were identified in each treatment group. Mean pre-operative MME was 10.3 (95% confidence interval [CI]: 7.4-13.2 MME) for the intervention group and 14.0 (95% CI: 10.2-17.8) for the control group (P=0.13). Patients who received a femoral nerve block also had shorter time from ED triage to hospital discharge (7.2 days, 95% CI: 6.2-8.0 days) than patients who received standard care (8.6 days, 95% CI: 7.2-10.0 days). Still, this difference was not statistically significant (P=0.09).

Conclusions

Femoral nerve blockade is a safe and effective alternative to opioids for pain control in patients with hip fractures.

A Comparison of Precision and Safety using Three Recognized Ultrasound-Guided Approaches to Cervical Medial Branch Blocks: A Cadaver Study

BACKGROUND

Ultrasound (US) guidance is widely used for needle positioning for cervical medial branch blocks (CMBB) and radiofrequency ablation, however, limited research is available comparing different approaches.

OBJECTIVE

We aimed to assess the accuracy and safety of 3 different US-guided approaches for CMBB.

STUDY DESIGN

A cadaveric study divided into ultrasound-guided needle placement and fluoroscopy evaluation stages.

SETTING

Department of Pathology, Forensic, and Insurance Medicine, Semmelweis University.

METHODS

Sonographically guided third occipital nerve (TON), C3, C4, C5 and C6 medial branch injections and radiology evaluations were performed.The 3 approaches compared were:1. ES (published by Eichenberger-Siegenthaler): US probe in the coronal plane to visualize the cervical articular pillars, needle approach out of the plane, from anterior to posterior.2. Fi (published by Finlayson): US probe in the transverse plane to visualize a cervical articular pillar and its lamina, needle approach in the plane, from posterior to anterior.3. FiM (Modified Finlayson approach): Needles are placed as in Fi, but then adjusted with a coronal view of the cervical articular pillars.Fluoroscopy images were taken and later evaluated, for "crude", "high precision" and "dangerous" placement.

RESULTS

One hundred and fifty-five needle placements were assessed (10 were excluded, as no anterior-posterior fluoroscopy images were saved). Interobserver agreement on position of needle placement between the 5 observers was very high; the Fleiss' Kappa was 0.921. For crude placement, no significant differences were identified between various approaches; (77.6%, 79.5%, and 75.6% for the ES, Fi, and FiM respectively). However, for placement in predefined high-precision zones, ES resulted in significantly more success (ES: 42.9%, Fi: 22.7%, and FiM: 24.4%, P = 0.032). Fi and FiM resulted in no dangerous placements, while ES led to the potential compromise of the exiting nerve root and vertebral artery on three occasions. In 10% of the placements, the levels were identified wrongly, with no difference between the various approaches.

LIMITATIONS

Feedback from a live patient, may prevent some existing nerve root injections, unlike in a cadaver. Though a higher number of needles were placed in this study than in most available publications, the number is still low at each individual medial branch level.

CONCLUSION

Fi proved safer than ES. Fi was equally successful in targeting the articular pillar, however, ES proved the most successful in placing the needle in the center of the articular pillar. Adding another, (coronal) US view to check needle position in FiM did not improve safety or precision. Identifying CMB levels with the US is challenging with all approaches, therefore we still recommend using fluoroscopy for level identification. While there were pros and cons with either procedure, the efficacy findings of previous papers were not replicated on elderly cadavers with arthritic necks.

Quadratus Lumborum Block

BACKGROUND

Laparoscopic sleeve gastrectomy (LSG) is a common bariatric surgery. Regional anesthetic techniques decrease postoperative pain, narcotic analgesic requirements, and opioid-related adverse effects in patients scheduled for bariatric surgery.

OBJECTIVES

The research team conducted this clinical trial to assess the effects of bilateral ultrasound (US)-guided erector spinae plane block (ESPB) on postoperative pain scores and postoperative analgesics consumption compared with bilateral US-guided quadratus lumborum block (QLB) in the first 24 hours following LSG.

STUDY DESIGN

A randomized, double-blind, prospective, single-center study.

SETTING

Ain-Shams University Hospitals.

METHODS

Patients: One hundred twenty morbidly obese patients were scheduled for LSG.

INTERVENTION

Were randomly assigned to 3 groups (40 each): bilateral US-guided ESPB, bilateral US-guided QLB, or control (C) group.

MEASUREMENTS

The time to first rescue analgesia (ketorolac) was considered as a primary outcome. The time to perform the block, the duration of anesthesia, the time to first ambulation, the visual analog scale (VAS) at rest, VAS at movement, the total nalbuphine consumption (mg), the total requirements of rescue analgesia (ketorolac) over the first 24 hours after surgery and the study safety profile were considered as secondary outcomes.

RESULTS

The time to perform the block and the duration of anesthesia were higher in the QLB group compared to other groups, with significant differences between ESPB and C groups (P < 0.001, P < 0.001, respectively). The ESPB and QLB groups were superior to the C group as regards the time to first rescue analgesia, the total dose of rescue analgesia, and the total nalbuphine consumption (P < 0.001, P < 0.001, P < 0.001, respectively). In the C group, VAS-R and VAS-M readings were higher in the first 18 hours after surgery (P < 0.001, P < 0.001, respectively). In the rest 6 hours of 24 hours after surgery, the QLB group had lower VAS-R and VAS-M readings than the C group (P < 0.001, P < 0.001, respectively). More patients in the C group had higher incidences of nausea and vomiting (P = 0.011, P = 0.002, respectively). In the C group, the time to first ambulation, the length of PACU stay, and the hospital stay were higher in comparison to the ESPB and QLB groups (P < 0.001, P < 0.001, P < 0.001, respectively). More patients in the ESPB and QLB groups were satisfied with postoperative pain management protocol (P < 0.001).

LIMITATIONS

The lack of postoperative respiratory assessment (e.g., spirometry) precluded the identification of either ESPB or QLB effects on pulmonary functions in such patients.

CONCLUSION

Bilateral ultrasound-guided erector spinae plane block and bilateral ultrasound-guided quadratus lumborum block provided adequate postoperative pain control and reduced postoperative analgesic requirements for morbidly obese patients scheduled for laparoscopic sleeve gastrectomy with priority to bilateral erector spinae plane block.

Ultrasound-guided Techniques for Perioperative Analgesia in Pediatric Lower Abdominal Surgeries: Quadratus Lumborum Block with Bupivacaine versus Caudal Bupivacaine and Neostigmine

BACKGROUND

Ultrasound-guided  regional anesthesia techniques for perioperative analgesia in pediatric patients scheduled for lower abdominal surgeries can be achieved either by quadratus lumborum block (QLB) or caudal block (CB). Neostigmine was co-administered with caudal bupivacaine to shorten the onset and extend the duration of analgesia.

OBJECTIVES

This study aimed to compare between 2 ultrasound-guided techniques used for perioperative analgesia (QLB with bupivacaine vs. CB with bupivacaine/neostigmine) regarding the total amount of rescue analgesic (acetaminophen mg/kg) used for pain relief at 24 hours postsurgery in pediatric patients undergoing lower abdominal surgeries in a developing country and to discuss existing barriers during the implementation of both techniques.

STUDY DESIGN

A randomized, double-blind, prospective, single-center study.

SETTING

Ain-Shams University Hospitals.

METHODS

Eighty pediatric patients scheduled for lower abdominal surgeries under general anesthesia were randomly allocated to receive either ultrasound-guided QLB using bupivacaine or ultrasound-guided CB using a bupivacaine/neostigmine mixture. The total amount of rescue analgesic (acetaminophen mg/kg) 24 hours postsurgery was considered as the primary outcome while the time to first rescue analgesia, pain score, postoperative nausea and vomiting, bradycardia, hypotension, and urinary retention were considered as secondary outcomes.

RESULTS

In the QLB group, the time to first rescue analgesia was longer whereas the total analgesic dose (mg/kg) was lower than the CB group (P < 0.001, P = 0.007, respectively). While, on the other hand, in CB group, the time to perform the block was shorter and Parents Satisfaction Score 24 h postsurgery was lower than the QLB group (P < 0.001, P < 0.001, respectively). Side effects were infrequent and comparable between the study groups.

LIMITATIONS

First, the researchers did not assess the dermatomal level before or after the operation in either group. Second, the investigators should have noticed the first voiding time to demonstrate accurately the incidence of urine retention. Third, a cost-effectiveness analysis of perioperative costs (drugs, staff, resources being used) of these regional anesthesia techniques when applied in an ambulatory setting should have been done, which would be helpful for those in resource-limited settings.

CONCLUSIONS

Postoperative analgesia for pediatric patients undergoing lower abdominal surgeries can be safely and effectively achieved by QLB with bupivacaine  and a CB with a bupivacaine/neostigmine mixture with priority given to CB, especially in resource-limited settings.

Spinal Interferon Regulatory Factor 8 and Brain-derived Neurotrophic Factor in the Prefrontal Cortex are Involved in Pain-induced Depression Relief via Ultrasound-guided Pulsed Radiofrequency in a Rat Spared Nerve Injury Model

BACKGROUND

Pain-depression comorbidity has become a great burden to individuals and society. Nevertheless, the mechanisms underlying comorbid diseases have still not been fully revealed. Ultrasound-guided pulsed radiofrequency (PRF) on peripheral nerves, which produces remarkable analgesia via high-frequency electromagnetic energy, has become a main, minimally invasive treatment for chronic neuropathic pain.

OBJECTIVES

The aim of this study was to explore the effect of ultrasound-guided PRF on the sciatic nerve of spared nerve injury (SNI) rats to relieve pain-induced depression.

STUDY DESIGN

Experimental trial in rats.

SETTING

The research took place in the Laboratory of The First Affiliated Hospital of Wenzhou Medical University.

METHODS

Sixty male Wistar rats were randomly divided into a sham group, an SNI group, an SNI + free-PRF group, and an SNI + PRF group. Ultrasound-guided PRF was applied to the sciatic nerve on day 7 after SNI. The basal paw mechanical withdrawal threshold (PMWT) was evaluated as a measure for pain-related behavior, and a  sucrose preference test was performed as a measure for depression-related behavior. The expression levels of spinal interferon regulatory factor 8 (IRF8) and of brain-derived neurotrophic factor (BDNF) in the prefrontal cortex (PFC) were also studied on days 21 and 42.

RESULTS

The results showed that the PMWT was significantly decreased in rats following SNI operation; the decreased levels of PMWT were reversed in the SNI + PRF group after the application of PRF on the sciatic nerve on day 7. There were no statistically significant differences among the groups in the sucrose preference rate on day 21 after SNI operation. The sucrose preference rate on day 42 was higher in the SNI + PRF group than in the SNI + free-PRF group. Western blot and reverse transcription polymerase chain reaction also demonstrated that ultrasound-guided PRF on the sciatic nerve downregulated overexpression of spinal IRF8 and increased the levels of BDNF in the PFC.

LIMITATIONS

This study was performed using only an SNI rat model which cannot represent all rodent neuropathic pain models. Only the short-term effectiveness of ultrasound-guided PRF on the sciatic nerve of SNI rats was investigated. The BDNF changes of other important brain areas were not taken into consideration in this study.

CONCLUSIONS

These findings suggest that ultrasound-guided PRF on sciatic nerve could alleviate pain-induced depression. The mechanisms of this treatment may be involved in the downregulated spinal IRF8 and the increased BDNF in PFC.

Value of deep learning models based on ultrasonic dynamic videos for distinguishing thyroid nodules

Objective

This study was designed to distinguish benign and malignant thyroid nodules by using deep learning(DL) models based on ultrasound dynamic videos.

Methods

Ultrasound dynamic videos of 1018 thyroid nodules were retrospectively collected from 657 patients in Zhejiang Cancer Hospital from January 2020 to December 2020 for the tests with 5 DL models.

Results

In the internal test set, the area under the receiver operating characteristic curve (AUROC) was 0.929(95% CI: 0.888,0.970) for the best-performing model LSTM Two radiologists interpreted the dynamic video with AUROC values of 0.760 (95% CI: 0.653, 0.867) and 0.815 (95% CI: 0.778, 0.853). In the external test set, the best-performing DL model had AUROC values of 0.896(95% CI: 0.847,0.945), and two ultrasound radiologist had AUROC values of 0.754 (95% CI: 0.649,0.850) and 0.833 (95% CI: 0.797,0.869).

Conclusion

This study demonstrates that the DL model based on ultrasound dynamic videos performs better than the ultrasound radiologists in distinguishing thyroid nodules.

Impact of preoperative oral domperidone on gastric residual volume after clear fluid ingestion in patients scheduled for elective surgery: a randomized controlled trial

INTRODUCTION

Oral domperidone is a prokinetic drug that enhances gastric emptying, which has a positive effect in decreasing gastric residual volume (GRV), subsequently decreasing the risk of pulmonary aspiration. This study aimed to assess the effect of preoperative oral domperidone on gastric residual volume, detected by ultrasound for patients undergoing elective surgery under general anesthesia.

MATERIAL AND METHODS

This randomized double-blinded controlled placebo trial was conducted in 40 patients who were randomly assigned to two equal groups: the domperidone group (D) ( n = 20): patients received 400 mL of apple juice as a clear fluid, two hours preoperatively, and an oral domperidone 10 mg tablet; and the placebo group (P) ( n = 20): patients received 400 mL of apple juice as a clear fluid two hours preoperatively with a placebo tablet. Gastric residual volume detected by ultrasound was the primary outcome and postoperative nausea and vomiting (PONV) was the secondary outcome.

RESULTS

There was no statistically significant difference in the mean gastric residual volume detected by ultrasound between groups after 1 hour ( P > 0.05). However, the mean gastric residual volume detected by ultrasound after 2 hours was statistically significantly lower with domperidone (55.95 ± 6.72 mL) than with the placebo group (70.22 ± 13.00 mL) ( P < 0.05). There was no statistically significant difference between groups regarding PONV, with a P -value > 0.05.

CONCLUSIONS

Preoperative oral domperidone intake was effective in decreasing the GRV measured by ultrasound.

The use of preoperative inferior vena cava ultrasound to predict anaesthesia-induced hypotension: a systematic review

Preoperative ultrasound assessment of inferior vena cava (IVC) diameter and the collapsi-bility index might identify patients with intravascular volume depletion. The purpose of this review was to gather the existing evidence to find out whether preoperative IVC ultrasound (IVCUS) derived parameters can reliably predict hypotension after spinal or general anaesthesia. PubMed was searched to identify research articles that addressed the role of IVC ultrasound in predicting hypotension after spinal and general anaesthesia in adult patients. We included 4 randomized control trials and 17 observational studies in our final review. Among these, 15 studies involved spinal anaesthesia and 6 studies involved general anaesthesia. Heterogeneity with respect to the patient populations under evaluation, definitions used for hypotension after anaesthesia, IVCUS assessment methods, and cut-off values for IVCUS-derived parameters to predict hypotension precluded pooled meta-analysis. The maximum and minimum reported sensitivity of the IVC collapsibility index (IVCCI) for predicting post-spinal hypotension was 84.6% and 58.8% respectively, while the maximum and minimum specificities were 93.1% and 23.5% respectively. For the prediction of hypotension after general anaesthesia induction, the reported ranges of sensitivity and specificity of IVCCI were 86.67% to 45.5% and 94.29% to 77.27%, respectively. Current literature on the predictive role of IVCUS for hypotension after anaesthesia is heterogeneous both in methodology and in results. Standardization of the definition of hypotension under anaesthesia, method of IVCUS assessment, and the cut-offs for IVC diameter and the collapsibility index for prediction of hypotension after anaesthesia are necessary for drawing clinically relevant conclusions.

Correlation between estimated fetal weight and weight at birth in infants with gastroschisis and omphalocele

BACKGROUND

An accurate estimated fetal weight (EFW) calculated with traditional formulae in cases of abdominal wall defects (AWDs) can be challenging. As a result of reduced abdominal circumference, fetal weight may be underestimated, which could affect prenatal management. Siemer et al. proposed a formula without the use of abdominal circumference, but it is not used in our protocols yet.

OBJECTIVES

Our aim was to evaluate the correlation of EFW and birth weight in fetuses with AWD by using Hadlock 1, Hadlock 2, and Siemer et al.'s formulae. Our secondary goal was to evaluate how often fetuses classified as small for gestational age (SGA) were in fact SGA at birth.

STUDY DESIGN

This was a retrospective cohort study of gestations complicated by gastroschisis and omphalocele at two tertiary-care centers in Brazil and Italy during an 8-year period. Of a total of 114 cases, 85 (44 cases of gastroschisis and 41 cases of omphalocele) met our criteria.

RESULTS

The last prenatal scan was performed 5.2 (±4.1) days before birth. The mean gestational age at birth was 37.2 (±1.8) weeks. Correlation of EFW with birth weight was calculated with the three formulae with and without adjustment for weight gain between scan and birth, with the use of the Spearman coefficient. The correlation between EFW and weight at birth was positive according to all three formulae for the infants with gastroschisis. This finding was not confirmed in the infants with omphalocele. All formulae overestimated the number of SGA cases: although only 17.6% of fetuses were actually SGA at birth, the Hadlock formulae had classified nearly 35% of them as SGA, and Siemer et al.'s formula, 15.3%.

CONCLUSION

All three formulae yielded a good correlation between EFW in the last scan and birth weight in the infants with gastroschisis but not for those with omphalocele. Cases of SGA were overestimated.

Ultrasound imaging and central venous pressure in spontaneously breathing patients: a comparison of ultrasound-based measures of internal jugular vein and inferior vena cava

BACKGROUND

Ultrasound evaluation of inferior vena cava and internal jugular vein dia-meters predicts the intravascular volume status in critical patients. The aim of the present study was to determine which ultrasound-derived index is most strongly associated with central venous pressure (CVP). Furthermore, we determined the utility of selected variables in predicting low volume status (CVP < 8 mmHg).

METHODS

All patients underwent a transthoracic echocardiogram, vascular ultrasound examination, invasive central venous pressure, and intra-abdominal pressure determination. The following indexes were calculated: inferior vena cava diameter, internal jugular vein maximum diameter, collapsibility index, and internal jugular vein ratio.

RESULTS

41 spontaneously breathing patients were recruited. Central venous pressure significantly correlated with inferior vena cava diameter ( r = 0.35, P = 0.02), internal jugular vein ratio ( r = 0.35, P = 0.03), and internal jugular vein maximum diameter ( r = 0.58, P < 0.001). The inferior vena cava collapsibility index did not show any association. The areas under the receiver operating characteristic curves to discriminate a low central venous pressure (< 8 mmHg) were the following: internal jugular vein diameter 0.80 (95% CI: 0.63-0.90); inferior vena cava diameter 0.66 (95% CI: 0.49-0.80); and internal jugular vein ratio 0.68 (95% CI: 0.51-0.82).

CONCLUSIONS

The internal jugular vein diameter, the internal jugular vein ratio, and the inferior vena cava diameter showed a significant correlation with central venous pressure. In particular, the internal jugular vein diameter showed good accuracy in predicting a low central venous pressure.

A Novel Piriformis Injection Technique Utilizing Combined Fluoroscopy and Ultrasound - A Pilot Study

BACKGROUND

Piriformis syndrome is a constellation of symptoms associated with low back, gluteal, and sciatic pain. One treatment for piriformis syndrome is the injection of local anesthetic, steroid, or botulinum toxin into the piriformis muscle. Various approaches for needle navigation into the piriformis muscle have been described using fluoroscopy or ultrasound. This study introduces a new method of image guidance combining fluoroscopy and ultrasound.

OBJECTIVES

The primary aim of this study was examining whether the imaging modality used for needle guidance was associated with significant differences in pre- and post-piriformis injection pain scores. Secondary objectives were assessing differences in adverse events and procedure time.

STUDY DESIGN

This study is a retrospective cohort study.

SETTINGS

This study was conducted at Oregon Health and Science University's Comprehensive Pain Center, Portland, OR, USA.

METHODS

Institutional chart review was performed from 09/21/2014 to 01/21/2020 to identify patients that underwent piriformis steroid injections which generated a list of 95 patients and totaled 154 procedures. Inclusion criteria were met for 78 patients and 109 procedures. Pain scores were modeled longitudinally using robust variance estimates. The nonparametric Kruskal-Wallis test was used for procedure duration, while adverse events were too rare to evaluate statistically.

RESULTS

Piriformis steroid injections using the combined ultrasound and fluoroscopy technique had the lowest mean post-procedure pain score of 1.3 (SD 1.7) and the largest change in pain with a score difference of -3.9 (SD 2.1). Procedure durations were 8 (quartiles 5 to 10), 10 (quartiles 7 to 13), and 11 minutes (quartiles 9 to 13) for fluoroscopy alone, ultrasound alone, and combined techniques, respectively. All 3 modalities had duration ranges of minimum time of 3-5 minutes and a maximum time of 25-28 minutes. Adverse events across all imaging strategies were noted in 5 patients at the time of procedure and in 7 patients during follow-up appointments, the most common symptom being transient leg weakness or numbness.

LIMITATIONS

The major limitation is the retrospective collection of data. Another limitation is that 6 different providers performed the injections, which may influence procedural consistency. Additionally, the inclusion of subjects with low pre-procedure pain scores could create a floor effect that minimized the occurrence of clinically significant shifts in pain scores. Adverse events were too few across all groups to assess.

CONCLUSION

Piriformis injections using combined fluoroscopic and ultrasound guidance provides comparable efficiency to standard techniques and may result in improved accuracy into the target and thus improved efficacy. Larger prospective trials are required to comprehensively examine the efficacy of this novel technique.

Ultrasound-Guided Regional Anesthesia Using a Head-Mounted Video Display: A Randomized Clinical Study

BACKGROUND

Ultrasonography is increasingly being used in every field of medicine, especially regional anesthesia. To successfully perform the procedure, a knowledge of anatomy and ultrasonoanatomy as well as technical 3D hand-eye coordination skills are required. Medical practitioners who use ultrasound devices to perform regional blocks have to correlate the position of the ultrasound probe on the patient, needle position, and ultrasound picture. To achieve that, the practitioner has to intermittently look between the patient and the ultrasonography screen. This requires extra head rotations, increasing the time and complexity of the procedure. Newer technologies are available that can alleviate the need for these extra head movements, such as head-mounted displays (HMDs), which are connected to the ultrasonography machine and project the ultrasonography picture onto the HMD goggles so that the provider can see the monitor without unnecessary head rotations.

OBJECTIVE

Our theory was that the use of the HMD goggles would decrease the overall procedure duration as well as provider head rotations.

STUDY DESIGN

This was a randomized clinical study.

SETTING

The research was conducted at an academic medical center at the University of Texas Medical Branch, Galveston, TX.

METHODS

We secured Institutional Review Board (IRB) approval to perform the study. We chose an HMD, which can be mounted on the head like regular goggles. By connecting the HMD with the ultrasonography machine, the ultrasound picture can be projected directly in front of the physician's eyes. Twenty-four patients were randomized to receive a regional anesthetic performed by anesthesiology residents using a conventional ultrasound-guided approach or using the HMD in addition. We measured the number of attempts, head rotations, and time needed to obtain a satisfactory nerve stimulation in addition to outcomes and adverse effects. Our data were interpreted by our statistician with P < .05 indicating statistical significance.

RESULTS

Regional anesthetics performed with the HMD were significantly faster (59.08 vs 175.08 seconds) with significantly fewer head movements (0.83 vs 4.75) and attempts (1 vs 1.42). There were no significant differences in patient demographics, type of regional anesthetic, level of resident training, or outcomes. No complications were noted.

LIMITATIONS

A limitation of our research is that neither observers nor providers were blinded to the way blocks were performed. This would have been practically impossible because participants had to wear an HMD.

CONCLUSIONS

The HMD could provide advantages in regional anesthesia by decreasing the time and attempts and improving ergonomics. These findings can be easily translated into other ultrasound- or optic/camera-guided procedures outside of regional anesthesia, such as vascular access or laparoscopic surgery.IRB: UTMB IRB #12-143.

A Randomized Comparison Between Two Injections from Two Planes versus Two Injections with a Uniplanar Approach for Ultrasound-Guided Supraclavicular Block

BACKGROUND

The brachial plexus courses along the lateral to posterior aspect of the subclavian artery located within the supraclavicular region as a trunk or division. Therefore we hypothesized that 2 injections, one along the lateral and one along the posterior aspect of the brachial plexus, could be performed by changing the angle of the ultrasound probe, thereby achieving a 3-dimensional (3-D) even distribution of local anesthetics. Previously, we confirmed the efficacy of this type of approach with that of a single cluster approach. These findings represent a subsequent study.

OBJECTIVES

This study was conducted to confirm the superiority of block quality achieved by 2 injections from 2 planes (control group; group C) over 2 injections in one plane (experimental group; group E).

STUDY DESIGN

A randomized, controlled trial.

SETTING

Department of Anesthesiology and Pain Medicine, Gachon University Gil Medical Center.

METHODS

In group C (n = 35), the brachial plexus sheath was penetrated in 2 planes by anteriorly altering the angle of the ultrasound probe without changing its position. In group E (n = 35), the upper and lower portions of the brachial plexus sheath were penetrated in one plane. A total of 15 mL of lidocaine 1.5% containing epinephrine (1:200,000) was injected at each point in both groups. The ultrasound-guided supraclavicular brachial plexus block was evaluated every 5 minutes for 30 minutes. The main outcome variables were rates of blockage of all 4 nerves and ulnar nerve sparing.

RESULTS

The rate of blockage of all 4 nerves (median, ulnar, radial, and musculocutaneous nerves) was not significantly different between the 2 groups (94% in group C vs. 86% in group E, respectively; P = 0.232). The number of spared ulnar nerves was similar (1 vs. 5, respectively; P = 0.088). Group procedure times, onset times, and Visual Analog Scale scores for the blocks were similar.

LIMITATIONS

For the 2 plane, 2 injection approach, only 2-D imaging was performed rather than 3-D imaging.

CONCLUSIONS

Two injections performed in one plane offered similar benefits to 2 injections performed in 2 planes. The 2 techniques provided comparable block qualities and could be viewed as equally effective alternatives.

A Comparison of the Effectiveness of Ultrasound-Guided Versus Landmark-Guided Suprascapular Nerve Block in Chronic Shoulder Pain: A Prospective Randomized Study

BACKGROUND

Suprascapular nerve block (SSNB) is an effective therapeutic approach for shoulder pain and has been increasingly used by professionals in clinical practice. In the landmark-guided nerve block technique, it could be difficult to determine the exact localization of the suprascapular nerve.

OBJECTIVES

To evaluate and compare the clinical and functional outcomes of ultrasound (US)-guided versus landmark-guided SSNB for the treatment of chronic shoulder pain.

STUDY DESIGN

Randomized, prospective analysis.

SETTING

Outpatient physical therapy and rehabilitation clinic.

METHODS

Seventy-two patients with chronic shoulder pain were enrolled into this study. The patients were randomly allocated to 2 groups. Thirty-six patients received US-guided SSNB and 36 underwent landmark-guided SSNB. Initial examinations before injection and for the first week and first and third months postinjection were recorded. Visual Analog Scale (VAS) pain intensity levels, shoulder functions based on the Shoulder Pain and Disability Index (SPADI), and quality of life levels based on the Health Assessment Questionnaire (HAQ) were evaluated at each control.

RESULTS

Statistically significant recovery was observed in terms of VAS pain levels, SPADI, and HAQ from the first week after injection in both groups, but no significant difference was observed between the groups.

LIMITATIONS

The absence of a control group.

CONCLUSIONS

Our results indicate that US-guided SSNB does not potentially offer a significantly greater clinical improvement over landmark-guided SSNB in patients with chronic shoulder pain. Further research is required to establish whether this hypothesis is consistently supported in practice.

[Advances in the imaging studies of post-prostatectomy urinary incontinence]

Radical prostatectomy is a standard surgical strategy for prostate cancer though with a few postoperative complications such as urinary incontinence, erectile dysfunction and vesicle urethral anastomotic stricture. Post-prostatectomy incontinence, as a common complication seriously affecting the patient's quality of life, is mainly diagnosed according to the clinical symptoms and the results of urodynamic and imaging examinations. Patients with post-prostatectomy incontinence may undergo corresponding anatomic and functional changes, which can be clearly and directly observed in imaging examination. This review focuses on the advances in the imaging studies of post-prostatectomy urinary incontinence from the perspectives of MRI, ultrasound and cystourethrography.

Clinical and Ultrasonographic Profile of Adalimumab-treated Hidradenitis Suppurativa Patients: A Real-life Monocentric Experience

Ultrasonography has proven useful for diagnosis and treatment monitoring in patients with hidradenitis suppurativa. The aim of this study was to assess the clinical response to adalimumab using ultrasound findings. This prospective study collected data on demographic features, disease severity, and hidradenitis suppurativa findings from patients with hidradenitis suppurativa treated with adalimumab. Generalized estimating equations investigated relationships between disease severity measures and clinical/demographic variables. The study included a total of 41 patients with hidradenitis suppurativa who were treated with adalimumab for a mean ± SD period of 50.8 ± 32.2 weeks; range 6–108 weeks). Clinical improvement was observed during adalimumab therapy, with a progressively greater number of patients achieving HiSCR50 response (36.4% at week 52). Disease duration was identified as the most relevant clinical variable affecting disease severity and treatment response. Treatment response was also influenced by treatment duration, with a 4% greater likelihood of achieving HiSCR50 response at each time-point. At the ultrasound examination, subcutaneous involvement of hidradenitis suppurativa lesions was identified as a predictive negative factor for clinical response to adalimumab (HiSCR50 achievement).

Short-term Effect and Acceptability of Manual Lymphatic Drainage for Paediatric Limb Lymphoedema: A Prospective Study

Paediatric lymphoedema (LE) is a rare condition, for which there is little data available regarding treatments. The aim of this study was to assess the short-term effect and acceptability of a 30-min session of manual lymphatic drainage (MLD) in children with well-documented LE of the lower limbs. Fifteen children were included (8 males; median age 11 years). Comparison of the sum of circumference values for the whole limb before and after MLD revealed a slight, but significant, reduction (from a median of 289.8 to 285.5 cm, p = 0.024), but the limb volumes did not decrease significantly (from a median of 4,870.3 to 4,772.3 ml, p = 0.394). Dermal thickness, measured by high-resolution ultrasound, decreased from 1.44 to 1.40 mm (p < 0.001). All children reported improvement in well-being, and found MLD useful. In conclusion, MLD is well accepted by children, but has poor impact on LE swelling. However, it decreases cutaneous oedema by mobilizing the lymph fluid.

[Clinical and ultrasonographic features of testis tumor in children of different ages]

OBJECTIVE

To explore the ultrasonographic characteristics of testis tumor in children of different ages.

METHODS

We retrospectively analyzed the clinical data, ultrasonographic results, surgical methods and pathological findings of 76 children with testis tumor treated in Shanghai Children's Hospital between April 2013 and March 2018. According to the age at the first diagnosis, we divided the patients into a 0－4 yr (n = 57) and a 5－12 yr group (n = 19), and compared the clinical manifestations, tumor markers, ultrasonographic features such as the tumor size, echogenicity, calcification and color flow images, pathological findings, and surgical methods between the two groups of patients.

RESULTS

Benign tumors were found in 73.4% of the 76 children and in 100% of the patients in the 5－12 yr group, with epidermoid cyst as the most common type (52.6% ［10/19］), 47.4% (9/19) found accidentally, 94.7% (9/19) without elevation of the alpha-fetoprotein (AFP) level, and 94.7% (9/19) treated by testis-sparing surgery (TSS). In the 0－4 yr group, teratoma and yolk sac tumors were the most common and 87.7% (50/57) of the cases were characterized by painless scrotal swelling with a normal or elevated AFP level, treated by TSS or radical orchiectomy. There were statistically significant differences between the two groups of patients in the clinical manifestations, AFP values, pathological findings and surgical methods (all P < 0.05), but not in the ultrasonographic results, mostly solid or mixed cystic-solid masses (χ2 = 0.908, P = 0.635). The maximum diameter of the tumors was smaller and the volume of the healthy contralateral testis was greater in the 5－12 yr than in the 0－4 yr group (t = 2.673 and 2.858, P = 0.009 and 0.010). The proportions of the tumors with calcification and those with grade 0 blood flow were significantly higher in the former than in the latter group (χ2 = 4.825 and 12.298, P = 0.028 and 0.006).

CONCLUSIONS

Testis tumors have different clinical and ultrasonographic features in children of different age groups, malignancy mostly in 0- to 4-year-olds while benignancy commonly in 5- to 12-year-olds, frequently with normal AFP, calcification, and less abundant color blood flow. TSS is recommended for the treatment of testis tumor with serum AFP negative in 5－12 years old children.