Deep Nerve Block Research Articles

Improved Pain and Function With Triamcinolone Acetonide Extended-Release and Cryoneurolysis for Knee Osteoarthritis: Use of a New Real-World Registry

BackgroundKnee osteoarthritis (OA) affects 19% of American adults aged more than 45 years and costs $27+ billion annually. A wide range of nonoperative treatment options are available. This study compared 6 treatments: cryoneurolysis with deep genicular nerve block (Cryo-Deep/Both), cryoneurolysis with superficial nerve block (Cryo-Superficial), intra-articular hyaluronic acid (IA-HA) injections, nonsteroidal anti-inflammatory drug injections (IA-NSAIDs), IA-corticosteroids (IA-CS) injections, or IA-triamcinolone extended release (IA-TA-ER) injections over 4 months for: (1) pain severity and analgesic use; and (2) physical function (from Knee Injury and Osteoarthritis Outcome Score for Joint Replacement). MethodsPatients who had unilateral knee OA and received nonoperative intervention were enrolled in the Innovations in Genicular Outcomes Research registry, a novel, multicenter real-world registry, between September 2021 and February 2024. A total of 480 patients were enrolled. Both pain and functional outcomes were assessed at baseline, weekly, and monthly, which were analyzed by overall trend, magnitude changes pretreatment to post-treatment, and distribution-based minimally clinically important difference (MCID) score. Multivariate linear regressions with adjustments for 7 confounding factors were used to compare follow-up outcomes among 6 treatment groups. ResultsUse of IA-TA-ER injections was associated with the lowest pain, greatest pain reduction, and highest prevalence of patients achieving MCID relative to other treatments (P < .001). Deep/Both-Cryo and IA-CS were associated with a higher prevalence of achieving MCID than IA-HA, IA-NSAIDs, and Cryo-Superficial (P ≤ .001). Use of IA-TA-ER was also associated with the greatest functional score, improvement from baseline, and highest prevalence of patients achieving MCID than other treatments (P ≤ .003). ConclusionsThe IA-TA-ER appears to outperform other treatments in terms of pain relief and functional improvement for up to 4 months following treatment. In addition, outcomes in the novel cryoneurolysis and conventional IA-CS were similar to one another and better than those in IA-HA and IA-NSAIDs.

Deep parasternal intercostal plane nerve block: an anatomical study

IntroductionThe superficial and deep parasternal intercostal plane (DPIP) blocks are two new blocks for thoracic pain. There are limited cadaveric studies evaluating the dye spread with these blocks. In this...

Lower extremity puncture wound.

A 58-year-old woman presented with pain after sustaining a right foot wound from a damaged wooden floor. Physical examination was remarkable for a 0.3-cm puncture wound between the first webspace on the plantar aspect of the foot with tenderness to palpation, but no visible or palpable foreign body. Plain radiographs were negative, and computed tomography of the foot noted the small puncture wound with a proximally extending linear tract. Orthopedic surgery was consulted but did not appreciate any foreign body and thus recommended conservative management without wound exploration in the emergency department (ED). Bedside ultrasound was then performed by emergency physicians that visualized a linear 4-cm hyperechoic foreign body with posterior acoustic shadowing (Figure 1, Video 1). Ultrasound-guided deep peroneal and posterior tibial nerve blocks were performed for anesthesia (Video 2). Under ultrasound guidance, curved forceps were used to grasp and remove a large wooden fragment (Figure 2, Video 3). The patient was discharged with oral antibiotics. Traumatic wounds are responsible for 11 million ED visits annually, and foreign bodies are involved in 7% to 15%.1 Many foreign bodies are missed on initial evaluation, and because of their risk for complications, they are frequently implicated in malpractice litigation.2 Plain film radiographs are considered first line and detect 80% of all foreign bodies but have a mere sensitivity of 15% for radiolucent objects, such as wood or other vegetative material.1, 3 Therefore, multimodal imaging is frequently necessary. Ultrasonography, performed in the ED setting, has an overall sensitivity and specificity of 91% for identifying foreign bodies.2 These will appear hyperechoic and may have additional clues, such as posterior acoustic shadowing, reverberation artifact, or hypoechoic halo. Using ultrasound to guide percutaneous foreign body removal can increase success in the ED to nearly 100%.4 Please note: The publisher is not responsible for the content or functionality of any supporting information supplied by the authors. Any queries (other than missing content) should be directed to the corresponding author for the article.

Periprocedural management of oral anticoagulation - Limit the bleeding risk in elective procedures

The decision to continue or to stop oral anticoagulant therapy in the peri-interventional period is based on the evaluation of bleeding risk associated with the invasive procedure or with the anaesthetic technique, especially when a deep nerve block or a neuraxial block is planned, and on the evaluation of patient-associated risk factors. Anticoagulant bridging during the preoperative period as well as an early resumption of anticoagulation in the postoperative period are associated with increased bleeding rates without reduction of thromboembolic events, thus limiting the indications of bridging to patients with chronic vitamin K agonist therapy and a high thrombotic risk.

Photoacoustic needle improves needle tip visibility during deep peripheral nerve block

We developed a novel technology using the photoacoustic effect that improve needle tip visibility. We evaluated whether this technology improves needle tip visibility when performing a deep peripheral nerve block in a cadaver model. A photoacoustic needle was developed using a conventional echogenic needle with an intraluminal optical fiber. A pulsed laser sends light from a source through the fiber, which is converted to ultrasound at the needle tip using the photoacoustic effect. A nerve block expert performed deep nerve blocks using the photoacoustic needle and the ultrasound views recorded, with or without photoacoustic ultrasound at the needle tip. Needle tip visibility was evaluated by questionnaire (Likert scale 1: very poor, 5: very good) completed by anesthesiologists evaluating recorded images. The score was presented as median [first quartile, third quartile]. Statistical analysis was performed using the Wilcoxon matched-pairs signed rank test. The scores of needle tip visibility with photoacoustic ultrasound from the needle tip (4.3 [4.0, 4.5]) was significantly higher than that without photoacoustic ultrasound (3.5 [3.2, 3.8]) (p < 0.01). Ultrasound emitted at the needle tip using the photoacoustic effect improves needle tip visibility during deep peripheral nerve blocks.Clinical trial number University Hospital Medical Information Network Center Clinical Trials Registration System (UMIN000036974).

The effect of needle tip tracking on procedural time of ultrasound-guided lumbar plexus block: a randomised controlled trial.

Technology that facilitates performance of deep peripheral nerve blocks is of clinical interest. The Onvision™ is a new device for ultrasonographic needle tip tracking that incorporates an ultrasound sensor on the needle tip that is then represented by a green circle on the ultrasound screen. The primary aim of this study was to investigate the effect of needle tip tracking on procedural time in the first human volunteer study. Secondary outcome measures included: number of hand movements; hand movement path length; block success rate; block onset time; block duration; discomfort experienced by the volunteers; and the anaesthetists' confidence as to whether their block would be successful. Two anaesthetists performed ultrasound-guided lumbar plexus blocks with an out-of-plane technique, with and without the use of needle tip tracking. In total, data from 25 volunteers were studied. Mean (SD) procedural time was 163 (103) s with needle tip tracking and 216 (117) s without (p=0.10). Hand motion analysis showed that needle tip tracking was associated with a significant decrease in the mean (SD) number of intended needling hand movements (39 (29) vs. 59 (36); p=0.03) and path lengths (3.2 (3.1)m vs. 5.5 (4.5)m; p=0.03). No differences were found for any other secondary outcomes. The use of Onvision needle tip tracking did not reduce procedural time for out-of-plane ultrasound-guided lumbar plexus block but did reduce the number of hand movements and path lengths. This may indicate improved needle control but further studies are needed to confirm this finding.

Combined ultrasound and nerve stimulator-guided deep nerve block may decrease the rate of local anesthetics systemic toxicity: a randomized clinical trial

BackgroundUltrasound guidance might decrease the incidence of local anesthetics systemic toxicity (LAST) for many peripheral nerve blocks compared with nerve stimulator guidance. However, it remains uncertain whether ultrasound guidance is superior to nerve stimulator guidance for deep nerve block of the lower extremity. This study was designed to investigate whether deep nerve block with ultrasound guidance would decrease the incidence of LAST compared with that with nerve stimulator guidance, and to identify associated risk factors of LAST.MethodsThree hundred patients undergoing elective lower limb surgery and desiring lumbar plexus blocks (LPBs) and sciatic nerve blocks (SNBs) were enrolled in this study. The patients were randomly assigned to receive LPBs and SNBs with ultrasound guidance (group U), nerve stimulator guidance (group N) or dual guidance (group M). The primary outcome was the incidence of LAST. The secondary outcomes were the number of needle redirection, motor and sensory block onset and nerve distribution restoration time, as well as associated risk factors.ResultsThere were 18 patients with LAST, including 12 in group U, 4 in group N and 2 in group M. By multiple comparisons among the three groups, we found that the incidence of LAST in group U (12%) was significantly higher than that in group N (4%)(P = 0.037) and group M(2%)(P = 0.006). The OR of LAST with hepatitis B (HBV) infection and the female sex was 3.352 (95% CI,1.233–9.108, P = 0.013) and 9.488 (95% CI,2.142–42.093, P = 0.0004), respectively.ConclusionsUltrasound guidance, HBV infection and the female sex were risk factors of LAST with LPBs and SNBs. For patients infected with HBV or female patients receiving LPBs and SNBs, we recommended that combined ultrasound and nerve stimulator guidance should be used to improve the safety.Trial registrationThis study was approved by the Ethical Committee of the First Affiliated Hospital of Army Medical University. The protocol was registered prospectively with the Chinese Clinical Trial Registry (ChiCTR-IOR-16008099) on March 15, 2016.

Superior gluteal nerve: a new block on the block?

The superior gluteal nerve is responsible for innervating the gluteus medius, gluteus minimus and tensor fascia latae muscles, all of which can be injured during surgical procedures. We describe an ultrasound-guided approach to block the superior gluteal nerve which allowed us to provide efficient analgesia and anesthesia for two orthopedic procedures, in a patient who had significant risk factors for neuraxial techniques and deep peripheral nerve blocks. An 84-year-old female whose regular use of clopidogrel contraindicated neuraxial techniques or deep peripheral nerve blocks presented for urgent bipolar hemiarthroplasty in our hospital. Taking into consideration the surgical approach chosen by the orthopedic team, we set to use a combination of general anesthesia and superficial peripheral nerve blocks (femoral, lateral cutaneous of thigh and superior gluteal nerve) for the procedure. A month and a half post-discharge the patient was re-admitted for debriding and correction of suture dehiscence; we performed the same blocks and light sedation. She remained comfortable in both cases, and reported no pain in the post-operative period. Deep understanding of anatomy and innervation empowers anesthesiologists to solve potentially complex cases with safer, albeit creative, approaches. The relevance of this block in this case arises from its innervation of the gluteus medius muscle and posterolateral portion of the hip joint. To the best of our knowledge, this is the first report of an ultrasound-guided superior gluteal nerve block with an analgesic and anesthetic goal, which was successfully achieved.

Usefulness of Shamrock View for Deep Nerve Blocks

Ultrasound guided nerve blocks have extremely developed in last one decade. However, Deep nerve blocks using ultrasound assist, especially the lumbar paravertebral region, have had disadvantage about the quality of the image and the artifact caused by bony structures compare with superficial nerve blocks. Recently, a novel approach to lumbar paravertebral region, Shamrock view reported by Sauter et.al., has attracted rising attention. There are several advantages in performing lumbar plexus block and quadratic lumbermen block for perioperative pain management, and lumbar root block and transforaminal epidural block for Interventional pain therapy. “Shamrock” was named from the ultrasound image of three muscle, psoas major muscles, quadratus lumborum muscle, and erector spine muscle, around lumbar transverse process as like three-leafs clover. This scan is superior to the standard posterior scan in the point that acoustic shadow of transverse process does NOT interfere the image of psoas major muscle. The needle visibility is also extremely better because of perpendicular reflection to the needle. Furthermore, structures in the lumbar spinal canal, dura and subarachnoid space, were also visible through the intervertebral foramen using Shamrock view. This provides a lot of information when we perform the lumbar paravertebral block and interventional procedures. We will present Tips of these techniques in our clinical practice.

SAT0197 Ultrasound Guided Musculoskeletal Procedures under Peripheral Nerve Block: A Pilot Controlled Study in Rheumatic Patients

BackgroundMusculoskeletal Ultrasound (US) is a valuable tool in the diagnosis and monitoring of rheumatic diseases. Invasive musculoskeletal procedures under US guidance improve technical accuracy and efficacy. However, patients complain of...

Ultrasound Guidance for Deep Peripheral Nerve Blocks: A Brief Review

Nerve stimulation and ultrasound have been introduced to the practice of regional anesthesia mostly in the last two decades. Ultrasound did not gain as much popularity as the nerve stimulation until a decade ago because of the simplicity, accuracy and portability of the nerve stimulator. Ultrasound is now available in most academic centers practicing regional anesthesia and is a popular tool amongst trainees for performance of nerve blocks. This review article specifically discusses the role of ultrasonography for deeply situated nerves or plexuses such as the infraclavicular block for the upper extremity and lumbar plexus and sciatic nerve blocks for the lower extremity. Transitioning from nerve stimulation to ultrasound-guided blocks alone or in combination is beneficial in certain scenarios. However, not every patient undergoing regional anesthesia technique benefits from the use of ultrasound, especially when circumstances resulting in difficult visualization such as deep nerve blocks and/or block performed by inexperienced ultrasonographers. The use of ultrasound does not replace experience and knowledge of relevant anatomy, especially for visualization of deep structures. In certain scenarios, ultrasound may not offer additional value and substantial amount of time may be spent trying to find relevant structures or even provide a false sense of security, especially to an inexperienced operator. We look at available literature on the role of ultrasound for the performance of deep peripheral nerve blocks and its benefits.

Ultrasound Does Not Improve the Success Rate of a Deep Peroneal Nerve Block at the Ankle

The deep peroneal nerve is 1 of 5 nerves anesthetized when performing an ankle block. Multiple techniques of blocking the deep peroneal nerve have been described, but little evidence exists to delineate the efficacy of any one technique. We hypothesized that ultrasound would increase both the success rate and the quality of a deep peroneal nerve block at the ankle. Eighteen healthy volunteers participated in this randomized, controlled, prospective study. Each subject was randomly assigned to receive an ultrasound-guided deep peroneal nerve block of either the right or the left ankle. The deep peroneal nerve on the opposite side was blocked using a conventional landmark technique. Subjects were blinded to the technique used. All blocks were preformed with 5 mL of 3% 2-chloroprocaine. We evaluated both sensory and motor blocks at 10-min intervals for 60 mins. Blocks were maximal in both groups at 20 to 30 mins. There was a statistically significant difference in temperature sensation and motor function at 10 mins favoring the ultrasound group. There was no statistical difference in motor function, temperature, or pinprick sensation between 20 and 60 mins. The use of ultrasound seems to improve the onset of deep peroneal nerve block at the ankle but does not improve the overall quality of the block.

Use of Masseteric and Deep Temporal Nerve Blocks for Reduction of Mandibular Dislocation

A patient presented with a unilateral dislocated condyle that was resistant to reduction by simple manual manipulation because of elevator muscle spasm and severe muscle and temporomandibular joint pain. A technique involving a masseteric nerve block and a temporal nerve block was used, allowing a quick, safe, and minimally painful reduction. The method used for delivering these nerve blocks is described here.

Caution: Maintain Anti-Platelet Therapy in Patients with Coronary Artery Stents

Caution: Maintain Anti-Platelet Therapy in Patients with Coronary Artery Stents

The influence of new antithrombotic drugs on regional anesthesia

Antithrombotic drugs are known to increase the risk of spinal epidural hematoma after neuraxial blockade. During the last few years, several new anticoagulants have been introduced, some of them more potent than the drugs currently available. More potency, however, may also indicate a higher risk of bleeding. Case series from the last few years indicate that spinal epidural hematoma is more common then previously estimated, with a prevalence from 1: 100,000 in obstetric patients to as high as 1: 3,600 in female orthopedic patients. In order to diminish this risk, most national societies have issued guidelines in which time intervals were established between administration of antithrombotic drugs and performance of neuraxial blockade. Guidelines are perceived to be capable of reducing the incidence of spinal epidural hematoma with the inherent risk of permanent paraplegia. These guidelines, however, will only be a valuable aid for clinicians if they are constantly updated and newer antithrombotic drugs are included. Although the resurge of peripheral nerve blocks may diminish patient hazards, deep nerve blocks such as lumbar sympathetic blockade are not devoid of serious complications and should probably be handled in the same way as neuraxial blockade.

Clinical experiences and dosage pattern in subcutaneous single-injection digital block technique

100 patients with injuries to their fingers were treated using the subcutaneous digital block as described by Low et al.. Different dosages ranging from 2 to 3 millilitres of a local anesthetic were required to obtain appropriate anesthesia according to the location of injury. 108 finger injuries were treated, 18 thumb injuries, 90 finger injuries. The anesthetic was administered using a 0.55 x 25 mm needle and injected strictly subcutaneously into the flexor crease at the base of the finger or thumb. Injuries to the palmar aspect of the fingers were anesthetized using 2 ml of a local anesthetic (1% Lidocain), whereas 3 ml were needed for sufficient pain relief in case of injury to the dorsal aspect of the fingers. Injury to the thumb required a higher dosage (3 ml subcutaneously), and only offered sufficient pain relief for palmar injuries. In the case of dorsal injuries, we found that this technique was not sufficient in providing pain relief. Additionally, we performed a deep local nerve block (Oberst), if the patient still felt discomfort or pain. The severity or type of injury did not play a role according to our findings. The subcutaneous finger block as described by Low et al., therefore, is the method of choice treating injuries to the fingers and to the palmar aspect of the thumb, since it offers a decrease in the amount of anesthetic required and increases patient comfort.

Blocks of the face and neck

Blocks of the face and neck are not commonly used in pediatric anesthetic practice. An appropriate nerve block provides excellent analgesia without distortion of the tissues that may occur with local infiltration. Meticulous attention to detail is required in performing a block of the face and neck because of the close relationship of the cranial and cervical nerves to vital structures. This necessitates the use of small discrete doses of local anesthetic because unintentional intravascular injection can produce rapid profound toxic effects, particularly when deep nerve blocks are performed. Correct needle placement can only be ensured by a thorough understanding of the anatomy of the area in which the block is to be performed. The anatomical landmarks, although relatively constant in the adult, may vary considerably in the growing child because the configuration of the neonatal skull changes dramatically before reaching maturity. This paper focuses on the general principles of nerve blocks of the face and neck, useful superficial nerve blocks for a particular region, and briefly on the principles of infiltration anesthesia in children.

Celiac plexus block for cancer pain

Pancreatic cancer is the fourth most common cause of cancer-related death in the United States, with an estimated 27,800 new cases in 1996. Pain is the most common presenting symptom, which remains prevalent in 80% to 85% of advanced pancreatic cancer cases. There is increasing evidence that neurolytic celiac plexus block (CPB) is an effective method to treat pain associated with intra-abdominal malignancies, especially pancreatic cancer. In addition, a recent study suggests that pain control with splanchnic neurolysis (similar to CPB) may improve survival time in certain pancreatic cancer patients. There are two basic approaches to perform CPB, which differ depending on the final needle placement relative to the diaphragm. The first approach is the retrocrural block (“classic” CPB or deep splanchnic nerve block), in which the injectate spreads posterior to the diaphragm. On the other hand, the second approach is the anterocrural block (“true” CPB), which results in the spread of injectate anterior to the diaphragm. Alcohol and phenol, in combination with a local anesthetic, are the most commonly used agents for neurolysis in CPB. Neurolytic CPB has been used extensively with good benefit and limited risk of adverse effects.

Vasomotor Responses in the Human Arm During Leg Exercise

Blood flow was measured in the hands and forearms of recumbent subjects by venous occlusion plethysmography during leg exer cise on a bicycle ergometer. In three highly practiced subjects, exercise resulted in a small fall in forearm flow and a moderate rise in arterial pressure. Resistance to blood flow was therefore considerably increased. Blocking the vasomotor fibers to forearm skin did not affect this, but blocking the deep nerves to the muscle vessels prevented the increase in vascular resistance during exer cise. Treating the forearm with bretyliurn tosylate had the same effect as deep nerve block. It was concluded that vasoconstrictor tone in muscle is increased during exercise. Since treating the forearm with atropine did not affect the normal response, it was concluded that activation of vasodilator fibers to muscle is not an integral part of the gen eral vasomotor response to exercise. Evidence was also found that the vasodilator outflow to a specific muscle group is not specifically activated when the muscle group in question is exercised. During fairly heavy exercise, vasodilatation occurred in both hand and forearm skin. In the hand this was preceded by vasoconstric tion. Evidence was found that the vasodila tation in the hand was due to release of vaso constrictor tone, whereas that in the forearm was mediated through vasodilator fibers. It is likely that the increase in heat production during exercise was responsible for the reflex vasodilatation in skin.