Ultrasound-guided pain interventions in the pelvis and the sacral spine

Ultrasound guidance of infiltrations in the management of chronic pain allows us to visualize in “real time” the advance of the needle and the diffusion of the analgesic agent in and around the pain-generating anatomical structures. It also enables us to avoid important structures, blood vessels, for example, located in the path of the puncture, thus, avoiding complications. The pelvic area has many pain-generating zones, including joints, muscles, and certain specific points, where nerve structures can be compressed. The involvement of these structures can produce pelvic or lower back pain along with pain that radiates to the lower limbs. Owing to its inability to penetrate bone, ultrasound is unable to visualize, and therefore infiltrate, a number of important nerves located on the anterior face of the sacrum, including the ganglion impar, inferior hypogastric plexus, and superior hypogastric plexus. In this article, we describe different techniques for the ultrasound-guided infiltration in the pelvic region, including the sacroiliac joint, pudendal nerve, coccygeal nerves, transsacral block, lateral branches of the posterior sacral roots, dorsal branch of the L5, caudal epidural infiltration, infiltration of the piriformis and gluteus medius muscles, infiltration of the iliolumbar ligament, ganglion impar block, and superior hypogastric plexus block.     

Ultrasound-guided ankle block. History revisited

Following forefoot surgery, compared to the traditional multimodal approach, regional anesthesia and analgesia provides high quality pain relief, decreases opioids consumption and leads to very high satisfaction scores. Traditional regional techniques relied either on wound infiltration, landmark technique ankle blocks or popliteal sciatic nerve block. Numerous anatomic variations of the different nerves might lead to failure following a blind technique.The current evolution towards ambulatory care will push surgical teams to favor techniques that simplify postoperative treatment and encourages immediate ambulation.The development of Ultrasound Guided Blocks has enabled us to perform very selective and precise nerve blocks.Ankle blocks provide excellent intraoperative anesthesia as well as long postoperative pain relief. Complications are rare using regional anesthesia for postoperative analgesia even after extensive foot surgery.Revival of ankle blocks is a perfect example of the high impact of new technological advances in improving ambulatory surgical care after foot surgery.     

超声引导在小儿区域麻醉中的应用

背景 超声技术在临床麻醉中已得到广泛应用,并且越来越多地被用于小儿区域麻醉.目的 超声通过实时成像方法来定位目标神经,使麻醉医师在实施小儿神经阻滞时能够直视各种解剖结构,观察穿刺针进针深度及局麻药扩散情况,从而提高了小儿神经阻滞的安全性及有效性,并减少了并发症.内容 目前研究集中于超声引导下各种小儿神经阻滞的实施及超声...     

The Efficacy and Safety of Regional Nerve Blocks in Total Hip Arthroplasty: Systematic Review and Direct Meta-Analysis

BackgroundRegional nerve blocks may be used as a component of a multimodal analgesic protocol to manage postoperative pain after primary total hip arthroplasty (THA). The purpose of our study was to evaluate the efficacy and safety of regional nerve blocks after THA in support of the combined clinical practice guidelines of the American Association of Hip and Knee Surgeons, American Academy of Orthopaedic Surgeons, Hip Society, Knee Society, and American Society of Regional Anesthesia and Pain Management.MethodsWe searched MEDLINE, Embase, and the Cochrane Central Register of Controlled Trials for studies published prior to March 24, 2020 on fascia iliaca, lumbar plexus, and quadratus lumborum blocks in primary THA. All included studies underwent qualitative and quantitative homogeneity testing followed by a systematic review and direct comparison meta-analysis to assess the efficacy and safety of the regional nerve blocks.ResultsAn initial critical appraisal of 3,382 publications yielded 11 publications representing the best available evidence for an analysis. Fascia iliaca, lumbar plexus, and quadratus lumborum blocks demonstrate the ability to reduce postoperative pain and opioid consumption. Among the available comparisons, no difference was noted between a regional nerve block or local periarticular anesthetic infiltration regarding postoperative pain and opioid consumption.ConclusionLocal periarticular anesthetic infiltration should be considered prior to a regional nerve block due to concerns over the safety and cost of regional nerve blocks. If a regional nerve block is used in primary THA, a fascia iliaca block is preferred over other blocks due to the differences in technical demands and risks associated with the alternative regional nerve blocks.     

Ultrasound‐guided peripheral nerve blocks: What are the benefits?

Background: Use of ultrasound by anaesthesiologists performing regional blocks is rapidly gaining popularity. The aims of this review were to summarize and update accumulating evidence on ultrasound-guided nerve blocks, with an emphasis on the clinical relevance of the results and to critically appraise changing standards in regional anaesthesia.
Methods: A search of MEDLINE and EMBASE (1966 to 31 December 2007) was conducted using the following free terms: 'ultrasound and regional anesthesia', 'ultrasound and peripheral block' and 'ultrasound and nerve and block'. These were combined with the MESH terms 'nerve block' and 'ultrasonography'. The following limits were applied: studies with abstracts, only in humans, published in core clinical journals. Trial type: meta-analysis, randomized-controlled trial and clinical trial.
Results: When peripheral nerves are adequately imaged by ultrasound, the concomitant use of nerve stimulation offers no further advantage. However, several studies reported problems with obtaining satisfactory images in some patients. Ultrasound guidance significantly shortened the block performance time and/or reduced the number of needle passes to reach the target in all comparative studies. The occurrence of paraesthesia during block performance was also reduced, but not the incidence of short-lasting post-operative neuropraxia. The frequency of accidental vascular punctures may be lower, but the data are contradictory. Block onset time was significantly shortened. Block duration was longer in children, but not in adults. Ultrasound also allowed dose reduction of the local anaesthetic (LA).
Conclusions: Ultrasound guidance shortens the block performance time, reduces the number of needle passes and shortens the block onset time. Blocks may be performed using lower LA doses.     

‘Small blocks’ in paediatric patients

Regional anaesthetic techniques are now extensively used in paediatric anaesthesia. A better understanding and conceptualization of them has led us to define a new category of blocks, termed compartment blocks, in which the structure that has to be identified is a fascial plane, not the nerve to be blocked itself. Some of these compartment blocks, most of which have been described decades ago but fell into disuse, have now been rediscovered as they offer many advantages in terms of safety, efficiency and simplicity. These ‘small blocks’ share the same high benefit/risk ratio and, basically, the same technique of fascial plane localization; this makes them look very similar even though they involve various structures and nerves with no real anatomical link. In this category are included the peri-umbilical, ilioinguinal/iliohypogastric, pudendal, penile, fascia iliaca, saphenous nerve, metacarpal and laryngeal nerve blocks. These small blocks provide adequate analgesia for a number of very common procedures in paediatric patients; they do not require special skills, training, complicated or expensive devices. Their success rate is extremely high and they have no true contraindications or significant adverse effects. They are effective with only small amounts of local anaesthetics and thus, due to their many advantages, should be used extensively in children.     

Ultrasound-guided blocks of the ilioinguinal and iliohypogastric nerve: accuracy of a selective new technique confirmed by anatomical dissection

Background. Ilioinguinal and iliohypogastric nerve blocks maybe used in the diagnosis of chronic groin pain or for analgesiafor hernia repair. This study describes a new ultrasound-guidedapproach to these nerves and determines its accuracy using anatomicaldissection control. Methods. After having tested the new method in a pilot cadaver,10 additional embalmed cadavers were used to perform 37 ultrasound-guidedblocks of the ilioinguinal and iliohypogastric nerve. Afterinjection of 0.1 ml of dye the cadavers were dissected to evaluateneedle position and colouring of the nerves. Results. Thirty-three of the thirty-seven needle tips were locatedat the exact target point, in or directly at the ilioinguinalor iliohypogastric nerve. In all these cases the targeted nervewas coloured entirely. In two of the remaining four cases partsof the nerves were coloured. This corresponds to a simulatedblock success rate of 95%. In contrast to the standard ‘blind’techniques of inguinal nerve blocks we visualized and targetedthe nerves 5 cm cranial and posterior to the anterior superioriliac spine. The median diameters of the nerves measured byultrasound were: ilioinguinal 3.0x1.6 mm, and iliohypogastric2.9x1.6 mm. The median distance of the ilioinguinal nerve tothe iliac bone was 6.0 mm and the distance between the two nerveswas 10.4 mm. Conclusions. The anatomical dissections confirmed that our newultrasound-guided approach to the ilioinguinal and iliohypogastricnerve is accurate. Ultrasound could become an attractive alternativeto the ‘blind’ standard techniques of ilioinguinaland iliohypogastric nerve block in pain medicine and anaestheticpractice.     

Ultrasound-guided fascia iliaca compartment block in pediatric patients using a long-axis, in-plane needle technique: a report of three cases

Ultrasound guided fascia iliaca compartment block (FICB) has not been previously described in pediatric patients. Reported here is an ultrasound guided long axis, in-plane needle technique used to perform FICB in three pediatric patients undergoing hip or femur surgery. Postoperative assessment revealed nerve blockade of the lateral femoral cutaneous, femoral, and obturator nerves or no requirement for narcotics in the PACU. FICB using this ultrasound guided technique was easy to perform and provided postoperative analgesia for hip and femur surgical procedures within the presumed distribution of the lateral femoral cutaneous, femoral, and obturator nerves.     

Headache in patients with cervical radiculopathy: a prospective study with selective nerve root blocks in 275 patients

Since many years we routinely use diagnostic selective nerve root blocks (SNRB) at our department when evaluating patients with cervical radiculopathy. Frequently patients who also presented with headache reported that the headache disappeared when the nerve root responsible for the radicular pain was blocked with local anaesthetics. Headache has been described as a companioning symptom related to cervical radiculopathy but has never before been evaluated with SNRB performed in the lower cervical spine. For this reason we added to our routine an evaluation of the response from the SNRB on headache in patients with cervical radiculopathy. The aim was to describe the frequency of headache in patients with cervical radiculopathy and its response to a selective nerve root block of the nerve root/roots responsible for the radiculopathy. Can nerve root compression in the lower cervical spine produce headache? In this consecutive series of 275 patients with cervical radiculopathy, 161 patients reported that they also suffered from daily or recurrent headache located most often unilaterally on the same side as the radiculopathy. All patients underwent a careful clinical examination by a neurosurgeon and a MRI of the cervical spine. The significantly compressed root/roots, according to the MRI, underwent SNRB with a local anaesthetic. The effect of the nerve root block on the radiculopathy and the headache was carefully noted and evaluated by a physiotherapist using visual analogue scales (VAS) before and after the SNRB. All patients with headache had tender points in the neck/shoulder region on the affected side. Patients with headache graded significantly more limitations in daily activities and higher pain intensity in the neck/shoulder/arm than patients without headache. After selective nerve root block, 59% of the patients with headache reported 50% or more reduction of headache and of these 69% reported total relief. A significant correlation was seen between reduced headache intensity and reduced pain in the neck, shoulder and arm. The result indicates that cervical root compression from degenerative disease in the lower cervical spine producing radiculopathy might also induce headache.     

Are peripheral and neuraxial blocks with ultrasound guidance more effective and safe in children?

Background and aims:  The efficacy and safety of ultrasound guided (USG) pediatric peripheral nerve and neuraxial blocks in children have not been evaluated. In this review, we have looked at the success rate, efficacy and complications with USG peripheral nerve blocks and compared with nerve stimulation or anatomical landmark based techniques in children.
Methods:  All suitable studies in MEDLINE, EMBASE Drugs and Cochrane Evidence Based Medicine Reviews: Cochrane Database of Systemic Reviews databases were identified. In addition, citation review and hand search of recent pediatric anesthesia and surgical journals were done. All three authors read all selected articles independently and a consensus was achieved. All randomized controlled trials (RCTs) comparing USG peripheral and neuraxial blocks with other techniques in children were included.
Results:  Ultrasound guidance has been demonstrated to improve block characteristics in children including shorter block performance time, higher success rates, shorter onset time, longer block duration, less volume of local anesthetic agents and visibility of neuraxial structures.
Conclusion:  Clinical studies in children suggest that US guidance has some advantages over more traditional nerve stimulation–based techniques for regional block. However, the advantage of US guidance on safety over traditional has not been adequately demonstrated in children except ilio-inguinal blocks.     

Systematic review of the effects of fascia iliaca compartment block on hip fracture patients before operation

Background

Fascia iliaca compartment block is used for hip fractures in order to reduce pain, the need for systemic analgesia, and prevent delirium, on this basis. This systematic review was conducted to investigate the analgesic and adverse effects of fascia iliaca block on hip fracture in adults when applied before operation.

The role of peripheral nerve stimulation in the era of ultrasound-guided regional anaesthesia

With the widespread use of ultrasound for localising nerves during peripheral nerve blockade, the value of electrical nerve stimulation of evoked motor responses has been questioned. Studies continue to show that, compared with nerve stimulation, ultrasound guidance alone leads to: significantly improved block success; decreased need for rescue analgesia; decreased procedural pain; and lower rates of vascular puncture. Nerve stimulation combined with ultrasound does also not appear to improve block success rates, apart from those blocks where the nerves are challenging to view, such as the obturator nerve. The role of nerve stimulation has changed in the last 15 years from a technique to locate nerves to that of an adjunct to ultrasound. Nerve stimulation can serve as a monitor against needle-nerve contact and may be useful in avoiding nerves that are in the needle trajectory during specific ultrasound guided techniques. Nerve stimulation is also a useful adjunct in teaching novices ultrasound-guided regional anaesthesia, especially when the position and or appearance of nerves may be variable. In this review, the changing role of nerve stimulation in contemporary regional anaesthetic practice is presented and discussed.     

Applications of ultrasound in paediatric anaesthesia

Ultrasound (US) scanning during the placement of major regional nerve blocks or intravascular catheters allows a non-invasive real-time image display of tissue planes, neurovascular structures and needles. Advances in scanner technology have allowed anaesthetists to accurately target needle placement, which enhances the success and safety of these procedures. This review will summarise the use of US for regional blockade and vascular cannulation in paediatric anaesthetic practice.     

The Efficacy and Safety of Regional Nerve Blocks in Total Knee Arthroplasty: Systematic Review and Direct Meta-Analysis

BackgroundRegional nerve blocks are widely used in primary total knee arthroplasty (TKA) to reduce postoperative pain and opioid consumption. The purpose of our study was to evaluate the efficacy and safety of regional nerve blocks after TKA in support of the combined clinical practice guidelines of the American Association of Hip and Knee Surgeons, American Academy of Orthopaedic Surgeons, Hip Society, Knee Society, and American Society of Regional Anesthesia and Pain Management.MethodsWe searched MEDLINE, Embase, and the Cochrane Central Register of Controlled Trials for studies published before March 24, 2020 on femoral nerve block, adductor canal block, and infiltration between Popliteal Artery and Capsule of Knee in primary TKA. All included studies underwent qualitative and quantitative homogeneity testing followed by a systematic review and direct comparison meta-analysis to assess the efficacy and safety of the regional nerve blocks compared to a control, local peri-articular anesthetic infiltration (PAI), or between regional nerve blocks.ResultsCritical appraisal of 1,673 publications yielded 56 publications representing the best available evidence for analysis. Femoral nerve and adductor canal blocks are effective at reducing postoperative pain and opioid consumption, but femoral nerve blocks are associated with quadriceps weakness. Use of a continuous compared to single shot adductor canal block can improve postoperative analgesia. No difference was noted between an adductor canal block or PAI regarding postoperative pain and opioid consumption, but the combination of both may be more effective.ConclusionSingle shot adductor canal block or PAI should be used to reduce postoperative pain and opioid consumption following TKA. Use of a continuous adductor canal block or a combination of single shot adductor canal block and PAI may improve postoperative analgesia in patients with concern of poor postoperative pain control.     

Ultrasound-guided supraclavicular brachial plexus block

In this study, we evaluated state-of-the-art ultrasound technology for supraclavicular brachial plexus blocks in 40 outpatients. Ultrasound imaging was used to identify the brachial plexus before the block, guide the block needle to reach target nerves, and visualize the pattern of local anesthetic spread. Needle position was further confirmed by nerve stimulation before injection. The block technique we describe aligned the needle path with the ultrasound beam. The block was successful after one attempt in 95% of the cases, with one failure attributable to subcutaneous injection and one to partial intravascular injection. Pneumothorax did not occur. Our preliminary data suggest that a high-resolution ultrasound probe can reliably identify the brachial plexus and its neighboring structures in the supraclavicular region. The technique of real-time guidance during needle advancement can quickly localize nerves. Distinct patterns of local anesthetic spread observed on ultrasound can further confirm accurate needle location. IMPLICATIONS: Real-time ultrasound imaging during supraclavicular brachial plexus blocks can facilitate nerve localization and needle placement and examine the pattern of local anesthetic spread.     

Spread of injectate with superficial cervical plexus block in humans: an anatomical study

Background. This study was undertaken to investigate why thesuperficial cervical plexus block for carotid endarterectomyis so effective. Initial consideration would suggest that asuperficial injection would be unlikely to block all terminalfibres of relevant nerves. One possibility is that the localanaesthetic crosses the deep cervical fascia and blocks thecervical nerves at their roots. Methods. Superficial cervical plexus blocks (injections justbelow the investing fascia) were performed using methylene blue(30 ml) in four cadavers. In one additional control cadaver,a deep cervical plexus injection was performed. In a secondcontrol cadaver, a subcutaneous injection (superficial to investingfascia) was performed at the posterior border of the sternomastoidmuscle. Results. Anatomical dissection showed that with superficialblock there was spread of the dye to structures beneath thedeep cervical fascia. In the first control, dye remained inthe deep cervical space. In the second control, dye remainedsubcutaneous. Conclusions. The superficial cervical space communicates withthe deep cervical space and this may explain the efficacy ofthe superficial block. The method of communication remains unknown.Our findings also indicate that the suitable site of injectionfor the superficial cervical plexus block is below the investingfascia of the neck, and not just subcutaneous. Br J Anaesth 2003; 91: 733–5     

超声引导下喉上神经阻滞研究进展

喉上神经的内支支配声门裂上方喉咽的大部分黏膜感觉,并涉及颈交感干和颈上神经节的分支。喉上神经阻滞不仅能阻断伤害性刺激,还能产生交感神经阻滞,阻滞区域主要包括咽部、会厌和声门裂上方喉黏膜的感觉神经。与盲法定位比较,超声引导下喉上神经阻滞安全性更高且并发症少,在临床中得到了广泛的应用。本文就喉上神经内支的应用解剖、超声定位方法、喉上神经阻滞的临床应用、不良反应及并发症进行综述,并对其研究进展进行总结和展望。     

Regional nerve blockade for early analgesic management of elderly patients with hip fracture – a narrative review

Elderly patients with hip fracture experience high morbidity and mortality, and are often undertreated for pain. Acute pain management in the elderly is challenging, with physiological frailty, medical comorbidities and cognitive impairment commonly compounding pain assessment and treatment. Guidelines outlining current best practice for acute pain management in the elderly now exist, but evidence suggests that practice remains variable and there continues to be scope for improvement. We conducted a narrative review of the literature to examine the challenges of acute pain management in the elderly, and to evaluate evidence for the role of regional nerve blocks for acute pain associated with hip fracture in the elderly. There is consistent evidence that regional nerve blocks can effectively reduce pain associated with hip fracture, providing rapid‐onset, site‐specific analgesia that is more effective than standard systemic analgesia alone. There is also moderate evidence that nerve blocks may contribute to reduced rates of delirium, and some suggestion of reduced length of inpatient stay, morbidity and mortality, although limited evidence is available. Fascia iliaca blocks are emerging as a block of choice, with evidence they can be safely and rapidly administered under ultrasound guidance in the acute setting, by both trained medical and nursing staff, with good effect. Ideally, comprehensive pain protocols for elderly hip fracture patients are required, that integrate evidence‐based fascia iliaca block use, timely and repeated pain assessment, and multidisciplinary orthogeriatric patient care.     

Applying ultrasound imaging to interscalene brachial plexus block

OBJECTIVE: Previous studies have examined ultrasound-assisted brachial plexus blocks, but few have applied this imaging technology to the interscalene region. We report a case of interscalene brachial plexus block using ultrasound guidance to show the clinical usefulness of this technology. CASE REPORT: A nerve stimulator-guided interscalene block was attempted for arthroscopic shoulder surgery but failed. Subsequent nerve localization was accomplished by ultrasound imaging using a high-frequency probe (5-12 MHz) and the Philips ATL HDI 5000 unit. Ultrasound showed nerves between the scalene muscles, block needle movement at the time of advancement, and local anesthetic spread during injection. Interscalene block was successful after 1 attempt of nerve localization and needle placement. CONCLUSIONS: Advanced ultrasound technology is useful for nerve localization and can generate brachial plexus images of high resolution in the interscalene groove, guide block needle placement and advancement in real time to targeted nerves, and assess adequacy of local anesthetic spread at the time of injection. Ultrasound imaging guidance can potentially improve success during interscalene brachial plexus block.