Regional Anesthesia & Pain Medicine

Response to "Ultrasound-guidedsubomohyoid suprascapularnerve block and phrenic nerveinvolvement: a cadaveric dyestudy: a promising nerve blockfor shoulder surgery" by Hongye et al

'Ultrasound-guided lateral, mid-shaft approach for proximal sciatic nerve block by Tedesco et al

Ultrasound-guided subomohyoid suprascapular nerve block and phrenic nerve involvement: a cadaveric dye study: a promising nerve block for shoulder surgery

Ultrasound-guided lateral, mid-shaft approach for proximal sciatic nerve block

Effect of early versus delayed activation of thoracic epidural anesthesia on plasma pro-atrial natriuretic peptide to indicate deviations in central blood volume during esophagectomy Background and Objectives A side effect to thoracic epidural anesthesia (TEA) is hypotension induced by central hypovolemia. This study addressed whether early activation (EA) versus late activation (LA) of TEA affects plasma pro-atrial natriuretic peptide (proANP) reflecting deviations in the central blood volume (CBV). We hypothesized that EA TEA would reduce plasma proANP, thus reflecting a decrease in CBV. Methods A randomized, controlled, single-blinded trial was conducted. Patients undergoing open esophagectomy were randomized to EA (n=25, after induction of general anesthesia) or LA TEA (n=25, after re-established gastric continuity) with the epidural catheter placed at the interspaces Th7-8 or Th8-9. Plasma proANP was determined repetitively along with hemodynamic variables and administration of fluid/vasopressors as postoperative complications were noted. Results With EA TEA, plasma proANP decreased following induction of anesthesia to the end of surgery (13%; 113±68 to 99±49 pmol/L; p=0.026), but that was not the case in the LA group (3%; 97±44 to 94±49 pmol/L; p=0.565) despite equal fluid balance (+1584±582 vs +1560±563 mL; p=0.888). Accordingly, the EA group required excessive treatment with vasopressors to maintain MAP >60 mm Hg during surgery (2.7±2 vs 1.6±1.4 ephedrine boluses; p=0.033 and infusion of phenylephrine for 216±86 vs 58±91 min; p<0.001). Plasma proANP and fluid balance were correlated only for EA patients (r=0.44; 95% CI 0.04 to 0.91; p=0.033). Conclusions EA TEA reduces plasma proANP indicating that CBV becomes affected. Based on a correlation between plasma proANP and fluid balance, a 2000 mL volume surplus of lactated Ringer's solution is required to maintain plasma proANP stable during open esophagectomy. Trial registration number 2014-002036-14 (https://www.clinicaltrialsregister.eu/ctr-search/search?query=2014-002036-14).

Trends in steroid agent and diluent choices for epidural steroid injections: a survey of Spine Intervention Society physicians Background Epidural steroid injections (ESIs) are a frequently used treatment for refractory radicular spinal pain. ESIs, particularly transforaminal epidural steroid injections (TFESI), may provide pain relief and delay the need for surgery. Corticosteroid agent and diluent choices are known to impact the safety of ESIs. In particular, the risk of embolization with particulate corticosteroids has led to recommendations for non-particulate steroid use by the Multisociety Pain Workgroup. Additionally, there is in vitro evidence that ropivacaine can crystalize in the presence of dexamethasone, potentially creating a particulate-like injectate. Despite widespread use and known risk mitigation strategies, current practice trends related to steroid and diluent choices are unknown. Objective Identify the use of particulate versus non-particulate corticosteroids for epidural steroid injections in the cervical and lumbar spine, as well as local anesthetics commonly used as diluents during these procedures. Methods Cross-sectional survey study of 314 physician members of the Spine Interventional Society. Results 41% and 9% of providers reported using particulate corticosteroids during lumbar TFESIs and cervical TFESI, respectively. Four per cent of providers reported the use of ropivacaine in cervical TFESIs. Forty-four per cent of respondents reported using anesthetic in cervical interlaminar ESIs. 21% of providers report using high volumes (> 4.5 mL) during cervical interlaminar ESIs. Conclusion Current trends, as assessed by this survey study, indicate substantial variability in steroid and diluent choice for ESIs. Patterns were identified that may impact patient safety including the continued use of particulate corticosteroids for TFESIs and the use of ropivacaine during TFESIs by a subset of respondents.

Upper trunk block for shoulder analgesia with potential phrenic nerve sparing: a preliminary anatomical report Background and objectives Ipsilateral phrenic nerve palsy (PNP) is an undesirable side of conventional approaches to interscalene brachial plexus blocks. The purpose of this study was to demonstrate whether or not the phrenic nerve can be spared by dye when injected at the division of the upper trunk of the brachial plexus. Methods Under ultrasound guidance, 5 mL of radiolabeled dye was injected between the anterior and posterior division of the upper trunk in two fresh, cryopreserved cadavers. CT scan analysis, cadaveric dissection, and cryosectioning were performed to examine the spread of the injectate. Results We found staining of the injectate over the entire upper trunk with its anterior and posterior divisions, the suprascapular nerve under the omohyoid muscle and the lateral pectoralis nerve, and the C5 and C6 roots. The middle trunk was partially stained. There was no evidence of dye staining of the lower trunk, anterior aspect of the anterior scalene muscle, or the phrenic nerve. Conclusions Our study offers an anatomical basis for the possibility of providing shoulder analgesia and avoiding a PNP.

Response to Dr Thomsons letter

Long-term efficacy of 1-1.2 kHz subthreshold spinal cord stimulation following failed traditional spinal cord stimulation: a retrospective case series

Dural puncture epidural analgesia for labor: a randomized comparison between 25-gauge and 27-gauge pencil point spinal needles Background This double-blind, randomized trial compared dural puncture epidural analgesia (DPEA) for labor using 25-gauge and 27-gauge pencil point spinal needles. We hypothesized that both needle sizes would result in similar onset time (equivalence margin=2.5 min) and therefore designed the study as an equivalence trial. Methods One hundred and forty patients undergoing labor were randomized to DPEA with 25-gauge (n=70) or 27-gauge (n=70) pencil point spinal needles. After the placement of the epidural catheter, a bolus of 20 mL of bupivacaine 0.125% and fentanyl 2 µg/mL was administered to all subjects. Thereafter, patients received boluses of 12 mL of bupivacaine 0.125% every 2 hours as needed. A blinded investigator recorded the onset time (defined as the temporal interval required to achieve a pain score ≤1 on a 0–10 scale), S2 block, sensory block height (30 min after the initial bolus of local anesthetic), presence of motor block (30 min after the initial bolus of local anesthetic), number of top-up doses required during labor and incidence of postural headache. Results Out of the 140 recruited patients, 135 were retained for analysis. Compared with their 27-gauge counterparts, 25-gauge pencil point spinal needles provided a 1.6 min shorter DPEA onset (95% CI of the difference of the means: –3.2 to –0.1 min). However, there were no intergroup differences in terms of S2 block, sensory block height, motor block, number of top-up doses and incidence of postural headache. Conclusion Dural puncture epidural analgesia with 25-gauge pencil point spinal needles provides a 1.6 min shorter onset time than DPEA with 27-gauge spinal needles. Although statistically significant, such a difference may not be clinically relevant. Further investigation is required to compare 25-gauge and 27-gauge spinal needles for DPEA in the setting of different local anesthetic infusion strategies. Trial registration number NCT03389945. Resurgence of peripheral nerve stimulation with innovation in device technologies Bayesian adaptive design: the future for regional anesthesia trials? Cervical plexus and greater occipital nerve blocks: controversies and technique update Fentanyl versus remifentanil-based TIVA for pediatric scoliosis repair: does it matter? Introduction Opioid-induced hyperalgesia (OIH) and acute opioid tolerance have been demonstrated extensively in patients undergoing adolescent idiopathic scoliosis (AIS) repair. Remifentanil infusion has been strongly linked to both tolerance and OIH in these patients; however, the impact of using an intraoperative fentanyl infusion has not been well studied. This study aims to determine if patients undergoing operative management of AIS have decreased opioid consumption and pain scores when an intraoperative fentanyl infusion is used as compared with a remifentanil infusion. Methods This is a retrospective chart review of patients with AIS who underwent posterior spinal fusion. During the period January 2012–June 2013, patients received remifentanil infusion as part of total intravenous anesthesia. From July 2013 to June 2015, remifentanil was replaced by fentanyl as standard protocol. The remifentanil cohort included 37 patients and the fentanyl cohort included 25 patients. The primary outcome was the total opioid consumption (morphine equivalents) in the first 24 hours postsurgery. Secondary outcomes included mean postoperative pain score in the first 24 hours postsurgery, postoperative opioid consumption 24–48 hours after surgery, time to extubation, time to assisted ambulation, length of stay, and incidence of postoperative nausea and vomiting. Results Compared with the remifentanil group, the fentanyl group had significantly higher postoperative opioid usage during the first 48 hours and significantly higher postoperative mean pain score during the first 24 hours. There was no difference between the two groups in mean pain score for 24–48 hours, extubation time, time to assisted ambulation, length of stay, or postoperative nausea and vomiting. Discussion Despite concerns for hyperalgesia and acute tolerance, remifentanil is widely used for intraoperative opioid infusions for surgical correction of AIS. This retrospective study examined a practice change from intraoperative remifentanil to intraoperative fentanyl as a potential approach to avoid OIH. Surprisingly, patients receiving fentanyl intraoperatively showed increased postoperative opioid use and pain scores in the first 24 hours postsurgery compared with the prior cohort receiving remifentanil. Substitution of fentanyl for remifentanil during surgical correction of AIS does not appear to solve the problem of OIH or acute tolerance. Prospective studies are needed to confirm this unexpected result. Greater analgesic effect with intermittent compared with continuous mode of lumbar plexus block for total hip arthroplasty: a randomized controlled trial Background and objectives Lumbar plexus block (LPB) is an effective perioperative analgesic therapy for patients undergoing total hip arthroplasty (THA). However, the analgesic efficacy of intermittent administration compared with continuous infusion of LPB in patients remains unclear. Methods Forty adult patients who underwent THA were randomly divided into two groups: continuous infusion group (6 mL/hour continuous infusion of levobupivacaine [0.125%] in LPB, n=20) and intermittent infusion group (12 mL of levobupivacaine [0.125%] bolus delivered every 2 hours in LPB, n=20). The primary outcome was the cumulative fentanyl consumption administered for rescue analgesia during the first 48 hours after surgery. Secondary outcomes were the number of demands for rescue analgesia and successfully delivered rescue analgesia; extent of sensory blockade (cold tests); and pain score on the visual analog scale (VAS) at rest and during mobilization during the first 48 hours after surgery. Results Both the cumulative fentanyl consumption administered for rescue analgesia (mean [SD]: 81.5 [58.5] μg vs 438 [101.2] μg among the intermittent infusion and the continuous infusion groups, respectively) and the number of demanded and delivered fentanyl boluses for rescue analgesia were lower in intermittent infusion group than in continuous infusion (p<0.001 for both). The extent of sensory blockade remained constant in intermittent infusion group, but gradually narrowed in continuous infusion. VAS was lower in intermittent infusion group than in continuous infusion, except at 1 and 12 hours postoperatively (p<0.05). Conclusions Greater analgesic effect was achieved using the intermittent mode than the continuous mode of LPB administration. Percutaneous peripheral nerve stimulation for the treatment of chronic neuropathic postamputation pain: a multicenter, randomized, placebo-controlled trial Background and objectives Chronic neuropathic pain is a common challenging condition following amputation. Recent research demonstrated the feasibility of percutaneously implanting fine-wire coiled peripheral nerve stimulation (PNS) leads in proximity to the sciatic and femoral nerves for postamputation pain. A multicenter, double-blinded, randomized, placebo-controlled study collected data on the safety and effectiveness of percutaneous PNS for chronic neuropathic pain following amputation. Methods Twenty-eight lower extremity amputees with postamputation pain were enrolled. Subjects underwent ultrasound-guided implantation of percutaneous PNS leads and were randomized to receive PNS or placebo for 4 weeks. The placebo group then crossed over and all subjects received PNS for four additional weeks. The primary efficacy endpoint evaluated the proportion of subjects reporting ≥50% pain reduction during weeks 1–4. Results A significantly greater proportion of subjects receiving PNS (n=7/12, 58%, p=0.037) demonstrated ≥50% reductions in average postamputation pain during weeks 1–4 compared with subjects receiving placebo (n=2/14, 14%). Two subjects were excluded from efficacy analysis due to eligibility changes. Significantly greater proportions of PNS subjects also reported ≥50% reductions in pain (n=8/12, 67%, p=0.014) and pain interference (n=8/10, 80%, p=0.003) after 8 weeks of therapy compared with subjects receiving placebo (pain: n=2/14, 14%; pain interference: n=2/13, 15%). Prospective follow-up is ongoing; four of five PNS subjects who have completed 12-month follow-up to date reported ≥50% pain relief. Conclusions This work demonstrates that percutaneous PNS therapy may provide enduring clinically significant pain relief and improve disability in patients with chronic neuropathic postamputation pain. Trial registration number NCT01996254. Radiofrequency ablation of genicular nerves prior to total knee replacement has no effect on postoperative pain outcomes: a prospective randomized sham-controlled trial with 6-month follow-up Background and objectives Refractory chronic knee pain from osteoarthritis (OA) is commonly treated with total knee arthroplasty (TKA). TKA can be associated with severe postoperative pain and persistent postsurgical knee pain. Poorly controlled postoperative pain can negatively effect functional outcomes following TKA, and effective opioid-sparing analgesia is key to the ideal recovery. Genicular nerve radiofrequency ablation (GN-RFA) has been shown in several trials to be clinically effective in patients with severe refractory knee pain from OA. We aimed to assess if preoperative GN-RFA would improve postoperative pain outcomes following TKA. Methods This was a sham-control prospective clinical trial in which blinded participants were randomized to image-guided GN-RFA or a simulated sham procedure 2-6 weeks prior to elective TKA. Outcomes were assessed at 48 hours and 1, 3 and 6 months following TKA. Results Seventy participants enrolled in this study. As compared with sham controls, GN-RFA had no treatment effect on postoperative opioid consumption, pain or functional measures at any time point. Conclusions Cooled RFA of the superior lateral, superior medial and inferomedial genicular nerves, when performed 2–6 weeks prior to elective TKA as part of a multimodal postoperative pain management regime, had no measurable effect on postoperative opioid use, analgesia use or function in the 48 hours following surgery. In addition, we found no longer term effect on outcome measures 1, 3 and 6 months after TKA. Trial registration number NCT02746874. Review of concentration yields in commercially available platelet-rich plasma (PRP) systems: a call for PRP standardization Platelet-rich plasma (PRP) has become increasingly popular in pain medicine with hopes of becoming a safe, effective alternative to routine treatments. However, given its autologous nature, PRP injectate may differ depending on the specific manufacturer and protocol. Currently, there is no standardization of reporting protocol. This systematic review compiles and standardizes values on PRP preparation and final product composition of platelets, white cell count, and growth factors for ease of comparison. On review of 876 studies, 13 studies were selected according to our inclusion criteria. Data from 33 PRP systems and protocols were extracted and standardized. Overall, PRP final product concentrations as well as PRP preparation protocols varied widely between systems. However, platelet concentration was directly correlated with both volume of blood collected and device centrifugal force. In conclusion, there is a large heterogeneity between PRP separation systems that must be resolved for proper study of this promising treatment. Response to BotulinumtoxinA in a migraine cohort with multiple comorbidities and widespread pain Background The phase III research evaluating migraine prophylaxis therapy (PREEMPT) protocol was developed in low-risk migraine patients. We studied longitudinal response to treatment in a sequential retrospective observational cohort to evaluate predictors of effectiveness in patients with multiple overlapping pain syndromes treated in a quaternary pain management clinic. Methods We evaluated indicators of individual response in 402 consecutive chronic migraine patients who provided demographic information and used the Collaborative Health Outcomes Information Registry. Results The patients were middle aged 47 (38–56) median (IQR) years old and 83% women. They reported multiple complex pain problems with 11 (6–18) regions represented on a pain body map. Evaluated with National Institutes of Health Patient-Reported Outcomes Measurement Information System measures, they reported higher scores for sleep impairment and disturbance, anxiety, depression, fatigue, pain behavior, pain interference and worse function and satisfaction with social roles compared with the general US population; p<0.001 for all domains. Within 120 days of treatment, 62% of patients reported reduced headache frequency. The best multivariable model developed for prediction of reduced headache frequency in response to treatment included lower treatment number, lower pain interference score, and less depression (p=0.001, 0.002, and 0.009). Depression may have been an obstacle to successful treatment; there was no association between depression score and number of treatments (p=0.54). Conclusions Our findings point to the importance of identifying and addressing pain interference and depression early in chronic migraine management and, more broadly, highlights the importance of multidisciplinary evaluation and treatment in chronic migraine. Complications associated with stellate ganglion nerve block: a systematic review Stellate ganglion nerve blockade (SGNB) is a vital tool in our armamentarium for the treatment of various chronic pain syndromes. SGNB can be performed using the traditional landmark-based approach, or with image guidance using either fluoroscopy or ultrasound. In this review, we systematically analyzed reported SGNB-related complications between 1990 and 2018. Seven databases were queried for SGNB between January 1, 1990 and November 27, 2018. Search results of the complications associated with SGNB were reported as per the Preferred Reporting Items for Systematic Reviews and Meta-Analyses recommendations. Out of a total of 1909 articles, 67 articles met our inclusion criteria, yielding 260 cases with adverse events. In 134 of the 260 (51.5%) cases, SGNB was performed with image guidance. Sixty-four (24.6%) and 70 (26.9%) of the complication cases reported the use of ultrasound and fluoroscopy guidance, respectively. One hundred and seventy-eight (68.4%) patients had medication-related or systemic side effects, and 82 (31.5%) had procedure-related or local side effects. There was one report of death due to massive hematoma leading to airway obstruction. There was one case report of quadriplegia secondary to pyogenic cervical epidural abscess and discitis following an SGNB. Complications following SGNB have been reported with both landmark-based techniques and with imaging guidance using fluoroscopy or ultrasound. In our systematic review, most adverse events that were reported occurred during or shortly after SGNB. Vigilance, American Society of Anesthesiologists standard monitors for conscious sedation, and accessibility to resuscitation equipment are vital to the safe performance of SGNB.

PostScript What should we call 'adductor canal'? Pablo Joaquín Moyano, Federico Gastón Mileo (2019-05-17) 10.1136/rapm-2019-100573 Not so fast! The argument for a simplified adductor canal block might not be so simple after all… Andrew Kenneth Lansdown, David Benjamin Yong, Alwin Chuan (2019-05-17) 10.1136/rapm-2019-100595 Hemidiaphragmatic paresis versus block failure: the effect of anesthetic volume reduction for supraclavicular plexus block Dan Sebastian Dirzu (2019-05-17) 10.1136/rapm-2019-100413 Response to "Ultrasound-guidedsubomohyoid suprascapularnerve block and phrenic nerveinvolvement: a cadaveric dyestudy: a promising nerve blockfor shoulder surgery" by Hongye et al Herman Sehmbi, Marjorie Johnson, Shalini Dhir (2019-06-07) 10.1136/rapm-2019-100688 Reply to: Randomized controlled trial of a simplified adductor canal block performed for analgesia following total knee arthroplasty Jeffrey D Swenson, Jennifer J Davis (2019-05-17) 10.1136/rapm-2019-100667 Ultrasound-guided subomohyoid suprascapular nerve block and phrenic nerve involvement: a cadaveric dye study: a promising nerve block for shoulder surgery Hongye Zhang, Yongsheng Miao, Zongyang Qu (2019-06-07) 10.1136/rapm-2019-100645 Long-term efficacy of 1–1.2 kHz subthreshold spinal cord stimulation following failed traditional spinal cord stimulation: a retrospective case series Simon Thomson (2019-05-22) 10.1136/rapm-2019-100473 'Ultrasound-guided lateral, mid-shaft approach for proximal sciatic nerve block' by Tedesco et al Takayuki Yoshida, Tatsuo Nakamoto (2019-06-07) 10.1136/rapm-2019-100703 Pain relief after total knee arthroplasty with vastus lateralis nerve block Siska Bjørn, Thomas Dahl Nielsen, Thomas Fichtner Bendtsen (2019-05-12) 10.1136/rapm-2019-100551 Gastric ultrasound: deep inspiration for stomach identification and localization Linda Le-Wendling, Barys Ihnatsenka, Yury Zasimovich et al. (2019-05-12) 10.1136/rapm-2019-100660 Ultrasound-guided lateral, mid-shaft approach for proximal sciatic nerve block Mario Tedesco, Giuseppe Sepolvere, Mario Cibelli (2019-06-07) 10.1136/rapm-2019-100657 Response to Dr Thomson's letter Leonardo Kapural, Shervin Harandi (2019-05-22) 10.1136/rapm-2019-100652 Original Article HTX-011 reduced pain intensity and opioid consumption versus bupivacaine HCl in bunionectomy: phase III results from the randomized EPOCH 1 study Eugene Viscusi, Joseph S Gimbel, Richard A Pollack et al. (2019-05-21) 10.1136/rapm-2019-100531 Trends in steroid agent and diluent choices for epidural steroid injections: a survey of Spine Intervention Society physicians Nathan Clements, Darrell Vydra, Daniel M. Cushman et al. (2019-05-24) 10.1136/rapm-2018-100366 Brief technical report Proximal lateral approach to ultrasound-guided sciatic nerve block: a volunteer and cadaveric study Jesper Kent Nielsen, Jørgen Tranum-Jensen, Søren Bøgevig (2019-05-17) 10.1136/rapm-2018-100203 Randomized comparison between epidural waveform analysis through the needle versus the catheter for thoracic epidural blocks Amornrat Tangjitbampenbun, Sebastián Layera, Vanlapa Arnuntasupakul et al. (2019-05-14) 10.1136/rapm-2019-100478 Case Report Indented intrathecal drug delivery system with loss of reservoir volume Vasudha Goel, Amol M Patwardhan, Mohab Ibrahim et al. (2019-05-12) 10.1136/rapm-2019-100516 Original article Pulsed radiofrequency to the dorsal root ganglion or the sciatic nerve reduces neuropathic pain behavior, decreases peripheral pro-inflammatory cytokines and spinal β-catenin in chronic constriction injury rats Ren Jiang, Ping Li, Yong-Xing Yao et al. (2019-05-14) 10.1136/rapm-2018-100032 Dural puncture epidural analgesia for labor: a randomized comparison between 25-gauge and 27-gauge pencil point spinal needles Felipe Contreras, Juan Morales, Daniela Bravo et al. (2019-05-22) 10.1136/rapm-2019-100608

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