Neurogenic thoracic outlet syndrome (NTOS) is an oft-overlooked and obscure cause of shoulder pain, which regularly presents to the office of shoulder surgeons and pain specialist. With this paper we present an otherwise healthy young female patient with typical NTOS. She first received repeated conservative treatments with 60 units of botulinium toxin injected into the anterior scalene muscle at three-month intervals, which providing excellent results of symptom-free periods. Later a trans-axillary first rib resection provided semi-permanent relief. The patient was followed for 10 years after which time the symptoms reappeared. We review the literature and elaborate on the anatomy, sonoanatomy, etiology and characteristics, symptoms, diagnostic criteria and treatment modalities of NTOS. Patients with NTOS often get operated upon – even if just a diagnostic arthroscopy, and an interscalene or other brachial plexus block may be performed. This might put the patient in jeopardy of permanent nerve injury, and the purpose of this review is to minimize or prevent this.
Ultrasound (US) use has rapidly entered the field of acute pain medicine and regional anesthesia and interventional pain medicine over the last decade, and it may even become the standard of practice. The advantages of US guidance over conventional techniques include the ability to both view the targeted structure and visualize, in real time, the distribution of the injected medication, and the capacity to control its distribution by readjusting the needle position, if needed. US guidance should plausibly improve the success rate of the procedures, their safety and speed. This article provides basic information on musculoskeletal US techniques, with an emphasis on the principles and practical aspects. We stress that for the best use of US, one should venture beyond the “pattern recognition” mode to the more advanced systematic approach and use US as a tool to visualize structures beyond the skin (sonoanatomy mode). We discuss the sonographic appearance of different tissues, introduce the reader to commonly used US-related terminology, cover basic machine “knobology” and fundamentals of US probe selection and manipulation. At the end, we discuss US-guided needle advancement. We only briefly touch on topics dealing with physics, artifacts, or sonopathology, which are available elsewhere in the medical literature.
The posterior triangle of the neck is an area of the body frequently visited by regional anesthesiologists, acute and chronic pain physicians, surgeons of all disciplines, and diagnosticians. It houses the entire brachial plexus from the roots to the divisions, the scalene muscles, the cervical sympathetic ganglions, the major blood vessels to and from the brain, the neuroforamina and various other structures of more or less importance to these physicians. Ultrasound (US) offers a handy visual tool for these structures to be viewed in real time and, therefore, its popularity and the need to understand it. We will discuss pertinent clinical anatomy of the neck and offer a basic visual explanation of the often-difficult two-dimensional (2-D) images seen with US.
The patients experienced postoperative continuous transversus abdominis plane blocks that seem to be of value in limiting opiate use and improving analgesia with daily activities in the acute postoperative phase after cesarean delivery.
IntroductionTourniquet pain may have cutaneous and ischemic components. It is questionable whether blockade of a sensory nerve will help reduce ischemic pain. In addition, complete anesthesia of the axilla in the intercostobrachial nerve (ICBN) distribution is challenging to execute, and ICBN blockade has an inherently higher failure rate because of its variable anatomic location and source of innervation. We sought to determine the utility of an ICBN block for the prevention of tourniquet pain. MethodsWe conducted a single-center randomized controlled trial at a major academic medical center involving patients scheduled to undergo distal upper extremity surgery under ultrasound-guided supraclavicular brachial plexus block. Forty patients were randomized to receive an additional ICBN block or no ICBN block, with 22 allocated to the intervention and 18 to control. We collected data on the incidence of tourniquet pain and systemic anesthetic requirements. ResultsInitial contingency analysis examining the relationship between ICBN block placement and the development of pain using the two-tailed Fisher exact test failed to show that the presence or absence of ICBN block was associated with the development of tourniquet pain. χ 2 analysis failed to show that tourniquet time was significantly related to the development of tourniquet pain. ConclusionsThe overall incidence of tourniquet pain in the setting of a dense supraclavicular brachial plexus block for surgical anesthesia was low even without an ICBN block and even with tourniquet times greater than 90 min. Tourniquet pain was easily managed with small amounts of systemic analgesics.
In this Pro-Con commentary article, we discuss the controversial debate of whether to provide peripheral nerve blockade (PNB) to patients at risk of acute extremity compartment syndrome (ACS). Traditionally, most practitioners adopt the conservative approach and withhold regional anesthetics for fear of masking an ACS (Con). Recent case reports and new scientific theory, however, demonstrate that modified PNB can be safe and advantageous in these patients (Pro). This article elucidates the arguments based on a better understanding of relevant pathophysiology, neural pathways, personnel and institutional limitations, and PNB adaptations in these patients.
Introduction: Spinal anesthesia is commonly used for total knee and hip arthroplasties (TKA/THA). The rising popularity of ambulatory TKA and THAs require anesthetic techniques that provide rapid recovery of motor and sensory function while minimizing side effects like postoperative urinary retention. This singlecenter retrospective observational study compares the recovery profile of patients undergoing TKA and THA under chloroprocaine spinals compared to hyperbaric and isobaric bupivacaine spinals.Methods: One hundred and twelve patients undergoing primary TKA and THA under spinal anesthesia at University of Florida Health were identified between September 1, 2019 and February 21, 2020. Their electronic medical records were reviewed. Patients were categorized based on the local anesthetic used in the spinal. Various demographic, intraoperative, and postoperative data were compiled and compared, including duration of surgery, time to physical therapy, time to post-anesthesia care unit (PACU) discharge, and time to spontaneous micturition.Results: Time to spontaneous micturition and PACU discharge were significantly lower in the chloroprocaine spinal group compared to the hyperbaric bupivacaine group by 193 minutes and 42 minutes, respectively. Fewer patients receiving chloroprocaine spinals had their first physical therapy session limited by residual motor weakness compared to those in both bupivacaine groups. Additionally, mean duration of surgery was shorter in the chloroprocaine group compared to both bupivacaine groups (89 minutes compared to 111 minutes). Time to physical therapy completion was not different. All groups had <10% conversion to general anesthesia.Conclusion: Chloroprocaine spinals can be feasible options for TKAs and THAs with improved postoperative recovery profiles compared to bupivacaine spinals.
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