10.4314/ajns.v9i2.70411

Background Deliberate self-harm with stone- or hammer-driven nail through the cranium is unusual. The need is stressed for comprehensive radiological evaluation with computed tomography (CT) scan, with or without angiography, and removal through an open cranial procedure under general anaesthesia, rather than extraction through a burrhole under local anesthetic infiltration. Methods We present here a 27-year old male who presented at our Teaching Hospital setting with a self-inflicted hand-driven intracranial nail to the left parietal region. He had a detailed neurological examination, was evaluated pre-operatively with computerised tomography of the brain and underwent an open cranial procedure under general anaesthesia for nail retrieval. Psychiatric unit evaluated and managed him for chronic depression. Results The transparietal, intraventricular 10cm long nail was retrieved and associated abscess evacuated by an open cranial procedure. Pre-operative neurological impairments regressed and his mood stabilized with anti-depressants. He was discharged without further deficits and has remained well for over four years Conclusion Self-inflicted hand-driven intracranial nail is a very rare form of penetrating cranio-cerebral trauma. Preoperative computerised tomography scan of the brain, meticulous open cranial removal under general anaesthesia and psychiatric management enable discharge without further injury or deficits. On the other hand, removal through a burrhole or just pulling out the nail would not allow intraoperative visualisation of associated lesions; the latter also predispose to further vascular and parenchymal brain injuries, worsening neurolological impairments.Key words: Intracranial Nail; Open Cranial Procedure; Psychiatric Evaluation.

Inguinal herniorrhaphy is one of the most frequent operations and can be successfully performed using general, regional, or local anesthesia. Epidemiological data from both nationwide (1) and large regional (2,3) databases have found that general anesthesia is used in 60%–70% of cases, central neuraxis blockade in 10%–20%, and local infiltration anesthesia in only 5%– 15% of cases. Even though local anesthesia with sedation (so-called monitored anesthesia care) is a more cost-effective anesthetic technique for inguinal hernia repair (4), general and spinal anesthesia remain the most popular anesthetic techniques at universitybased teaching programs. Interestingly, specialized hernia centers use local infiltration anesthesia in more than 95% of these cases (5– 8).

Introduction: Peripheral nerve block for pain relief in elective foot surgery is recommended by the national institute for clinical excellence. The aim of the current study was to evaluate this. Material and Methods: In a retrospective study on the quality of pain relief in 100 patients undergoing elective foot and ankle surgery using, the degree of pain relief, and the duration of anaesthesia was analysed. Three methods of local infiltration was used, US guided, guided by anatomical landmark and local infiltration at site of surgery. The data was collected using a questionnaire, assessed and discussed with the anaesthetic and the orthopaedic team. The surgery was for elective foot conditions with the patient under general anaesthesia. Results: Local surgical site infiltration was used in in 40 cases, Ultrasound guided (USG) local anaesthetic injection was given for 30 of cases, and infiltration using anatomical land mark was given in for 30 cases. The duration of anaesthesia was longer when USG block was used after general anaesthesia. The degree of pain relief was similar between blocks and local surgical site infiltration. Conclusion: Local surgical site infiltration at the end of the operation is effective in pain relief following foot surgery and is less time and cost consuming.

The changing role of monitored anesthesia care in the ambulatory setting.

Hypothermia and Hyperthermia in the Ambulatory Surgical Patient

Mandibular nerve block in addition to cervical plexus block for carotid endarterectomy.

Delivery by caesarean section (CS) is becoming more frequent. Childbirth is an emotion-filled event, and the mother needs to bond with her baby as early as possible. Any intervention that leads to improvement in pain relief is worthy of investigation. Local anaesthetics have been employed as an adjunct to other methods of postoperative pain relief, but reports on the effectiveness of this strategy are conflicting. This review attempted to assess the effects of local anaesthetic agent wound infiltration and/or abdominal nerve blocks on pain after CS and the mother's well-being and interaction with her baby. Methods. We searched the Cochrane Pregnancy and Childbirth Group's Trials Register (April 2009).The selection criteria were randomised controlled trials of local analgesia during CS to reduce pain afterwards. Twenty studies (1 150 women) were included. Results. Women who had wound infiltration after CS performed under regional analgesia had a decrease in morphine consumption at 24 hours compared with placebo (morphine dose -1.70 mg; 95% confidence interval (CI) -2.75 to -0.94). Women who had wound infiltration and peritoneal spraying with local anaesthetic after CS under general anaesthesia (1 study, 100 participants) had a reduced need for opioid rescue (risk ratio (RR) 0.51; 95% CI 0.38 to 0.69). The numerical pain score (0 -10) within the first hour was also reduced (mean difference (MD) -1.46; 95% CI -2.60 to -0.32). Women with regional analgesia who had local anaesthetic and non-steroidal anti-inflammatory cocktail wound infiltration consumed less morphine (1 study, 60 participants; MD -7.40 mg; 95% CI -9.58 to -5.22) compared with those who had local anaesthetic control. Women who had regional analgesia with abdominal nerve blocks had decreased opioid consumption (4 studies, 175 participants; MD -25.80 mg; 95% CI -50.39 to -5.37). For outcome in terms of the visual analogue pain score (0 - 10) over 24 hours, no advantage was demonstrated in the single study of 50 participants who had wound infiltration with a mixture of local analgesia and narcotics versus local analgesia. Conclusions. Local anaesthetic infiltration and abdominal nerve blocks as adjuncts to regional analgesia and general anaesthesia are of benefit in CS by reducing opioid consumption. Non-steroidal anti-inflammatory drugs may provide additional pain relief.

In 1884 Carl Koller published his work on local anesthesia with cocaine for eye surgery. Within a year over 60 reports on the use of local anesthesia with cocaine were...

Objective To compare the safety of early (≤4 h) versus 24 h tube feeding after percutaneous endoscopic gastrostomy (PEG) tube placement and to determine the effectiveness of i.v. sedation combined with ultrasound-guided, left side transversus abdominis plane (TAP) block versus combination with local anesthetic (LA) infiltration for PEG placement. Background Tube feeding used to be delayed up to 24 h after PEG placement, but results from many randomized controlled trials revealed that there was no need for delaying the tube feeding. The procedure was earlier done with general anesthesia or i.v. sedation with LA infiltration, but the use of i.v. sedation with TAP block may be another option. Patients and methods This was a prospective randomized study including 60 patients, requiring long-term nutritional support, who underwent the PEG procedure at GIT Endoscopy Unit, Damanhour Teaching Hospital, El Beheira, Egypt; between August 2017 and March 2018. Patients were randomly allocated into two equal groups, in group A; early tube feeding (≤4 h) was done and performed with i.v. midazolam and propofol-based sedation combined with ultrasound-guided, left side TAP block, whereas in group B; delayed tube feeding (24 h postprocedure) was done and performed with i.v. midazolam and propofol-based sedation with LA infiltration. Results There were no statistically significant differences between both groups with respect to procedure-related or anesthesia-related complications. Conclusion Early tube feeding (≤4 h) after PEG placement may be a safe option to delayed (24 h postprocedure) feeding. I.v. sedation combined with ultrasound-guided, left side TAP blockade can be used successfully as the primary anesthetic modality for PEG placement.

Submucosal resection is accompanied by significant post-operative pain and discomfort. The aim of this randomized, double-blinded clinical trial was to study the efficacy of a local block anaesthetic, delivered after induction of general anaesthesia, in reducing post-operative pain. Patients aged 16 years and over who were scheduled for elective submucosal resection were randomly assigned to receive either standardized general anaesthesia, general anaesthesia with local anaesthetic infiltration or general anaesthesia with placebo infiltration. Haemodynamic stability, intra-operative blood loss, post-operative pain (over a seven day follow-up period), analgesics consumption, hospital stay, and the patient's and surgeon's levels of satisfaction were assessed. We found significantly lower results for pack removal pain score, volume of intra-operative blood loss, number of patients suffering from headache, altered dental sensation or nasal pain, number of patients who consumed analgesics, and length of hospital stay, comparing the infiltration group with the general anaesthesia and placebo groups (p<0.05). This clinical trial showed that infiltration with the local anaesthetics fentanyl and clonidine substantially reduced post-operative pain and shortened patients' hospital stay.

Comparison of local and regional anesthesia modalities in breast surgery: A systematic review and network meta-analysis

Analgesia that facilitates early mobilisation is crucial for achieving the best possible outcome after knee arthroplasty and may reduce chronic post-surgical pain [1]. Peri-articular local infiltration anaesthesia offers effective analgesia and is recommended by the National Institute for Health and Care Excellence [2]. Regional anaesthesia techniques such as adductor canal block offer a desirable combination of sensory nerve blockade with minimal risk of quadriceps weakness but have unproven overall benefit [3]. Reflecting this, national guidelines do not recommend routine use of adductor canal block, and the National Institute for Healthcare Research (NIHR) has commissioned a trial to establish whether regional analgesia improves outcomes [4]. We conducted an online survey of practice to understand variation in the practice of anaesthesia for knee arthroplasty in the UK using https://www.onlinesurveys.ac.uk and to explore equipoise for a trial of adductor canal block in this population. The survey was distributed to the mailing list of the National Research Scotland Anaesthesia, Anaesthesia and Peri-operative Medicine Subspecialty Group, contacts in the Peri-operative Medicine Clinical Trials Network and professional contacts of the REALISE trial group. The survey asked about primary anaesthetic; regional anaesthesia (including type, drug, concentration and volume); local infiltration (including approach, technique and additives); adjustments for partial or robotic knee arthroplasty; and trial equipoise. Of the 161 responses, three were excluded as the respondent did not regularly provide anaesthesia for knee arthroplasty. Of the remainder, most came from anaesthetists in Scotland or Northern England (n = 116, 73%). In total, 128 (81%) respondents thought the NIHR-commissioned call asked an important research question. The majority of responders (n = 147, 93%) worked in centres where < 25% of all cases were undertaken as day-case procedures. Spinal anaesthesia was the primary technique of choice (n = 150, 95%). Adductor canal block was employed routinely by 85% (n = 134); one responder used femoral nerve blocks instead of adductor canal blocks. Additional nerve blocks were used rarely (n = 4, 2.5%) and always combined with an adductor canal block. Twenty-three (15%) responders stated they performed no peripheral nerve blocks. Surgical local anaesthetic infiltration was usually performed (n = 146, 92%) and mostly combined with adductor canal block (n = 122, 77%). Focused infiltration of the posterior capsule was more common (n = 55, 58%) than peri-articular infiltration (n = 40, 42%). In addition, 54 (34%) responders reported that adrenaline, tranexamic acid, ketorolac or diclofenac were added to the local infiltration mixture. Most responders used levobupivacaine for adductor canal block (n = 119/134, 89%), but there were variations in the drug, concentration and volume (Table 1). Most common was 20 ml 0.25% levobupivacaine. The volume varied between 10 and 60 ml. Although there is no consensus ‘ideal’ volume, an excessive volume of local anaesthetic may migrate proximally into the femoral triangle or distally into the popliteal fossa resulting in inadvertent motor block [3]. Conversely, it is important that local anaesthetic reaches distally within the adductor canal to block various nerves that lie within it at that level, including the articular branch of the obturator nerve [5]. Fifteen responders adjusted their technique for partial knee arthroplasty including low-dose spinal (n = 3); no block (n = 5); general anaesthesia (n = 2); low dose adductor canal block (n = 3); and low-dose spinal plus general anaesthesia (n = 2). Most responders had no experience with robotic knee arthroplasty or did not change management. Some responders did propose adjustments for robotic knee arthroplasty including general anaesthesia (n = 7); higher dose spinal (n = 7); lower dose ACB (n = 1); and lower dose spinal plus general anaesthesia (n = 1). Despite the popularity of the adductor canal block, most respondents felt the NIHR Health Technology Assessment commissioned a call to determine whether they improve pain outcomes when added to local infiltration anaesthesia in knee arthroplasty is a question that needs to be answered. The survey was designed by the authors with input from the wider REALISE Investigator Group (REALISE Investigators: Aryelly Rodriguez Carbonell, Simon Chillingworth, Lesley Colvin, Nick Clement, Andrew Duckworth, Michael Gillies, David Griffith, Samantha Jones, Steff Lewis, David McDonald, Carol Porteous, David Semple, Ben Shelley and Andrew Stoddart). DG has received travel expenses and hospitality from Armstrong Medical. DG has also received speaking fees from Fresenius Kabi (2021) and for BD advisory board participation (2020). In both cases, fees were paid directly to DGs group at the University of Edinburgh. No other competing interests declared.

In this retrospective study, we compared the costs for three different regional anesthesia techniques with the costs of general anesthesia (GA). A total of 1587 anesthesia cases which were performed for orthopedic and trauma patients over a 1-yr period in a tertiary level, university hospital setting were analyzed. The anesthesia technique-related costs were determined calculating case-specific costs for personnel, supplies, and drugs. The techniques were compared on the basis of anesthesia costs and surgical procedure duration. As a result, we found that the costs per surgical minute largely depend on the surgical procedure duration. Based on the regression function, the cost advantage of spinal anesthesia over GA can be estimated to be 13% for a 50-min case, 9% for a 100-min case, and 5% for a 200-min case. The cost disadvantage of brachial plexus anesthesia over GA can be estimated to be 19% for a 50-min case, 8% in a 100-min case, and 1% for a 200-min case. We found no difference in costs between epidural and GA. We concluded that cost comparisons of anesthesia techniques largely depend on the surgical duration of the cases studied. Even in a teaching hospital setting, spinal anesthesia has economic advantages over GA. Especially for short cases, brachial plexus block is more expensive in this setting.

General and spinal anesthesia are currently in widespread use during transurethral bladder tumor resection. However, local anesthetic methods are claimed to provide sufficient intra-operative analgesia and satisfactory post-operative pain management. We evaluated whether local levobupivacaine infiltration of the tumor would result in outcomes, in terms of intra-operative analgesia, similar to those for utilization of general anesthesia. Post-operative analgesia and patient satisfaction were also assessed. Twenty patients with recurrent solitary bladder tumors were randomly allocated in two groups. Group A, underwent tumor resection under general anesthesia and group B was treated with resection after local levobupivacaine infiltration. Post-operative analgesia was evaluated with utilization of a visual analogue scale, ranging from 0 to 10, with higher scores indicating more intense pain perception. Group A patients demonstrated significantly lower visual analogue scale scores at t=0, which peaked at 4 h post-operatively. Group B scores were higher at t=0, declined over a 2 h interval and reached zero after t=4 h. Patients younger than 60 years and women benefitted more. Local anaesthesia was the method of pain control preferred by 90% of patients. Local levobupivacaine infiltration for transurethral bladder tumor resection seems feasible, providing intra and post-operative pain control. In this preliminary setting, general anesthesia provided a higher level of pain control in the immediate post-operative period (<4 h) while local levobupivacaine infiltration demonstrated excellent late post-operative analgesia (>4 h). Also, patients seem to prefer local to general anesthesia in future surgery.

Unilateral biportal endoscopy (UBE)-assisted transforaminal lumbar interbody fusion (TLIF) is an evolving minimally invasive option for lumbar instability. We evaluated outcomes of a lateralized, extra-flaval UBE-TLIF technique that preserves the ligamentum flavum and leverages anatomic/vascular landmarks within Kambin's triangle. Retrospective series of 58 consecutive cases (single surgeon, January 2024 to January 2025). All procedures were performed under general endotracheal anesthesia with local portal-site infiltration. Interbody preparation and cage insertion were performed through a lateralized extra-flaval corridor under biplanar fluoroscopy with percutaneous pedicle screw-rod fixation in all cases without navigation and intraoperative neuromonitoring. The primary outcomes analysis evaluated Oswestry Disability Index and visual analog scale (VAS) back and leg pain scores preoperatively and at 2 weeks, 1 month, 6 months, and 1 year. Paired t tests assessed within-patient change. In the analyzed cohort (n = 58), Oswestry Disability Index improved from 83.28 ± 7.31 preoperatively to 41.48 ± 10.16 (2 weeks), 17.73 ± 5.91 (1 month), 11.17 ± 3.71 (6 months), and 6.31 ± 3.72 (1 year; all P < 0.001). VAS back pain decreased from 7.81 ± 1.02 to 5.26 ± 1.55, 2.47 ± 1.96, 0.60 ± 0.92, and 0.40 ± 0.79; VAS leg pain decreased from 7.86 ± 0.91 to 2.09 ± 1.14, 1.14 ± 0.61, 0.88 ± 0.53, and 0.47 ± 0.57 (all P < 0.001). One cage migration required revision; no postoperative infections or new motor deficits occurred. Transient dysesthesia occurred in 4/58 patients (6.9%), resolving conservatively. Extra-flaval, lateralized UBE-TLIF with percutaneous pedicle screw fixation, performed under general anesthesia with local infiltration and guided by fluoroscopy without navigation or neuromonitoring, yielded rapid, durable improvements in disability and pain at 12 months with a low complication rate. Flavum preservation and precise corridor definition may enhance neural safety and facilitate large-cage insertion. Prospective studies with standardized fusion assessment are warranted. This study provides evidence that endoscope-assisted UBE lumbar TLIF offers significant and sustained improvements in functional disability and pain scores, supporting its use as a minimally invasive treatment option for symptomatic lumbar spondylolisthesis.