According to ultrasound, the palpated intercristal line falls at the L3-4 interspace, or below, in the majority of subjects positioned for neuraxial block in the sitting position. A palpated intercristal line at L2-3 was more likely in tall and male individuals.
Purpose: To report on the efficacy of peripheral plexus catheters in the treatment of ischemic pain in spite of nerve stimulation with long current impulses. Clinical features:Two patients with severe neuropathic ischemic foot pain are described. A 56-yr-old man with diabetes, renal failure, and autonomic neuropathy presented with severe ischemic foot pain. Opioids produced excess sedation and hypotension. A 62-yr-old woman was admitted after femoralpopliteal bypass and developed a reperfusion pain syndrome not relieved with opioids, gabapentin, amitryptiline, and clonidine. In both patients, a sciatic plexus catheter was placed with resolution of pain. Conventional nerve stimulation, which uses a pulse duration of 0.1 msec, did not result in muscle contraction. However, by using a nerve stimulator capable of delivering a 1.0 msec impulse duration, a muscle twitch or paresthesia endpoint ensued allowing for successful catheter placement. Conclusion:Peripheral plexus catheters provide a safe alternative to systemic analgesics for pain relief in patients with ischemic foot pain. However, conventional nerve stimulation techniques may not elicit a motor response in patients with underlying neuropathy, and the use of nerve stimulators capable of delivering long current impulses is recommended.Objectif : Présenter l'efficacité des cathéters de plexus périphéri-que utilisés dans le traitement de la douleur ischémique malgré la stimulation nerveuse avec de longues impulsions de courant.
One of the most fascinating developments in regional anesthesia in recent years has been the advent of ultrasound technology. This advancement has led to a rejuvenation of the field, and practitioners with varying experience in regional anesthesia and use of ultrasound want to use this tool to perform blocks. Consequently, a structured approach to the use and application of ultrasound is greatly needed for all practitioners. The recently published textbook, An Introductory Curriculum for Ultrasound-Guided Regional Anesthesia; A Learner's Guide, is certainly timely and essential. The textbook is divided into five sections, which are further subdivided into one to three chapters. The sections are organized logically with one chapter flowing seamlessly into the next. In the thoughtful Foreword and
Introduction:The intercristal line (ICL) is a common clinical landmark used to guide the level for neuraxial techniques. We sought to determine if ultrasonography of the spine, while in clinical positioning for a spinal or epidural anesthetic, confirms the classical teaching that the ICL occurs at the L3/4 intervertebral space. Methods: After obtaining ethics approval and informed consent, non-gravid, elective surgical patients and volunteers were examined in conventional position (seated, spine flexed) for neuraxial techniques by a single observer. The ICL was identified by palpation of the iliac crests and the skin at this level was marked with erasable pen. Paramedian ultrasound (SonoSite® MicroMAXX™ 2-5 MHz curved array probe) identified the vertebral level at which the palpated ICL occurred. The proportion of ultrasound assessments of ICL found at L2/3, L3/4, and L4/5 were compared with Fisher's Exact test. P < 0.05 was considered significant. Results: Thirty-three of fifty males (66.7 %) and fifty of sixty-four females (78.1 %) had an ICL at L3/4. Six males (12.0 %) and ten females (15.6 %) had an ICL at L4/5, P = 0.54. Eleven males (22.2 %) and four females (6.3 %) had an ICL at L2/3, P < 0.02. Height, age, waist circumference, mass, and body mass index were not related to ICL level in males or females. Discussion: In clinically relevant position for neuraxial techniques, the majority of males and females had an ultrasound-measured intercristal line at L3/4. However, significantly more males than females had an intercristal line at L2/3. This should be taken into account when determining a safe needle insertion point for subarachnoid techniques given that up to 10% of the population may have a conus medullaris extending caudal to L2 (1).
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