Faster Motor Recovery Research Articles

Novel lumbar plexus block versus femoral nerve block for analgesia and motor recovery after total knee arthroplasty.

This study aimed to compare the postoperative analgesic efficacy and motor recovery of a novel lumbar plexus block (LPB) with that of a femoral nerve block (FNB) after total knee arthroplasty (TKA). Forty patients who underwent TKA were randomised equally into an lumbar plexus and sciatic nerve (LS) group (receiving novel LPB) and an femoral and sciatic nerves (FS) group (receiving FNB). The assessed variables were the onset time of pain, time to the first analgesic request, pain scores, motor block at 6, 12, and 24 h after TKA, and the number of patients receiving successful blockade for each branch of the lumbar plexus. In the LS group, the femoral, lateral femoral cutaneous, genitofemoral, iliohypogastric, ilioinguinal, and obturator nerves were blocked in 18, 20, 16, 18, 15, and 19 patients. Compared to the FS group, the LS group had a significantly shorter onset time of pain and time to the first analgesic request, a significantly larger total postoperative dose of sufentanil, significantly higher numeric rating scale scores for both rest and dynamic pain at 6, 12, and 24 h, and faster motor recovery. Novel ultrasound-guided LPB has a high blocking success rate and provides inferior postoperative analgesia, but faster motor recovery after TKA than FNB.

Abstract 15651: Astrocytic Chordin-Like 1 Regulates AMPAR Synaptic Content and Motor Recovery in a Mouse Model of Ischemic Stroke

Introduction: Ischemic stroke triggers a series of molecular events that impairs receptor levels at excitatory synapses. AMPA receptors (AMPARs), the main excitatory receptors in the mammalian brain, are crucial in maintaining proper brain function. In response to ischemic stroke, their subunit composition and location at the synapse are deeply altered and trigger apoptotic cell death cascades. We previously found that Chordin-like 1 (Chrdl1), an astrocyte-derived protein that regulates AMPARs, is highly upregulated in the peri-infarct region at early stages after stroke (1 and 7 days post-stroke, dps). When Chrdl1 was absent, neurons were protected from stroke-induced structural degeneration. Hypothesis: Elimination of Chrdl1 prevents stroke-induced aberrant AMPAR synaptic levels, limits AMPAR-mediated apoptotic cascades and alleviates behavioral deficits. Methods: We used photothrombosis to model ischemic stroke in the motor cortex of adult male and female WT and Chrdl1 KO mice and performed analyses at 1 and 7 dps in the peri-infarct area. We used fluorescent in situ hybridization to analyze mRNA levels of Chrdl1, immunohistochemistry to determine synaptic AMPAR levels and subunit composition, TUNEL to determine apoptotic cell death, MRI to monitor the progression of injury volume, and adhesive removal and grid walk tests to assess sensorimotor and motor behaviors. Results: WT mice, after photothrombotic injury showed important impairments in the AMPAR synaptic distribution and composition. This aberrant AMPAR subunit composition and location at synapses was abolished in Chrdl1 KO mice. This resulted in reduced apoptotic cell death and faster motor recovery in Chrdl1 KO mice compared to WT in both male and female mice. Conclusions: This study shows that targeting Chrdl1 has therapeutic potential to reduce apoptotic cell death and aid motor recovery after ischemic stroke via synaptic regulation of AMPARs. Astrocyte-derived proteins, such as Chrdl1, may represent new molecular targets that can restore synapses to favor functional recovery after ischemic stroke.

Elbow Flexion Reconstruction in Brachial Plexus Avulsion Injuries - Results with Intercostal Nerve and Distal Nerve Transfers.

Background: The neural surgical options for reconstruction of elbow flexion in brachial plexus injuries depend on the availability of nerve donors. In upper-type avulsion injuries, the ulnar or median nerves, when intact, are reliable intra-plexal donor nerves for transfers to the biceps muscle. In complete avulsion injuries, donors are limited to extra-plexal sources, such as intercostal nerves (ICNs). Methods: We reviewed our results of ICN and partial distal nerve (ulnar or median) transfers for elbow flexion reconstruction in patients with brachial plexus avulsion injuries. The time taken for recovery of elbow flexion strength to M3 and the final motor outcome at 2 years were compared between both groups. Results: 38 patients were included in this study. 27 had ICN transfers to the musculocutaneous nerve (MCN), 8 had partial ulnar nerve transfers and 3 had partial median nerve transfers to the MCN's biceps motor branch. The mean time interval from injury to surgery was 3.6 months. Recovery of elbow flexion was observed earlier in the distal nerve transfer group (p < 0.05). Overall, success rates were higher in patients with distal nerve transfers (100%), compared to ICN transfers (63%) at 2 years (p = 0.018). Patients with distal nerve transfers achieved a higher final median strength of M4.0 [Interquartile range (IQR) 3.5-4.5], compared to M3.5 (IQR 2.0-4.0) in the ICN group (p = 0.031). In the subgroup of patients with upper-type brachial plexus injuries, there were no significant differences in motor outcomes between the ICN versus distal nerve transfers group. Conclusions: In our entire cohort, patients with distal nerve transfers had faster motor recovery and better elbow flexion power than patients with ICN transfers. In patients with partial brachial plexus injuries, outcomes of ICN transfers were not inferior to distal nerve transfers.

Do We Need Cephalic Spread of Spinal Anaesthesia for Caesarean Section? A Different Approach to CSE-EVE for Reducing Hypotension

Spinal anaesthesia is the most preferred anaesthetic technique for elective as well as for unplanned Caesarean sections. Spinal-induced hypotension remains the most important side effect with a reported incidence between 20% and 100%. It can cause -maternal discomfort (nausea and vomiting) and impaired utero-placental perfusion. The present study was designed to examine the influence of epidural volume effect on the spread and duration of low-dose hyperbaric levobupivacaine. The aim of this study was to evaluate the influence of epidural restriction (injection of saline) on the distribution of anaesthesia as well as the incidence of hypotension during the spinal anaesthesia.After the approval by the ethics committee, 60 full-term parturient women (ASA I or II) with uncomplicated pregnancies were prospectively randomized into 2 groups: the SA group (single shot spinal anaesthesia) included 37 patients and the CSE-EVR group (combined spinal-epidural anaesthesia) included 39 patients in whom we induced the restriction of the spinal space by epidural volume compression. The blocks were performed at the L2/3 or L3/4 level in a sitting position, in the CSE-EVR group using the needle-through-needle technique. The initial dose for CSE-EVR was exactly half of the SA dose (0.5 mg per 10 cm height of hyperbaric levobupivacaine and 20 microg fentanyl). After spinal injection, an epidural catheter was located in the CSE-EVR and a volume of 20 mL saline solution injected. After injection, the women were turned supine with a left uterine displacement. Surgery was allowed when a sensory block at or above the T8 dermatome was established. We evaluated the height of the block by the pinprick method and the motor block by the Bromage scale, 10 min after spinal injection, during the operation time and at the end of surgery. Haemodynamic monitoring (NIBP, HR) was assessed every 2 min until the childbirth, then every 5 min during operative time. Anaesthetic efficacy was evaluated for breakthrough pain by visual analogue pain score (VAPS), Apgar score at birth, umbilical artery pH, and epinephrine consumption.The level of anaesthesia 10 min after the induction was significantly higher in the spinal group (SA) than in the CSE-EVR T5 (T4-T7) vs. T7 (T6-T8) group.The SA group experienced complete motor block during the time of anaesthesia, while the CSE-EVR group demonstrated significantly faster motor recovery. The incidence of hypotension and ephedrine supplementation was significantly lower in the CSE-EVR group (19 vs. 35 patients) than in the SA group (p<0.05).The neonatal outcome and umbilical artery pH were higher in the CSE-EVR group. Both groups were comparable in demographic data, VAS scores, preloading and infusion volume, atropine or ephedrine use, and adverse effects such as nausea or skin pruritus.We demonstrated a possible restriction of the spread of spinal anaesthesia by using epidural volume restriction with 20 mL saline as part of a combined spinal epidural technique. The study shows that CSE with EVR using only 50% of the levobupivacaine dose provided adequate anaesthesia for elective Caesarean delivery, as well as better maternal haemodynamic stability.

Correction: Do We Need Cephalic Spread of Spinal Anaesthesia for Caesarean Section? A Different Approach to CSE-EVE for Reducing Hypotension.

Spinal anaesthesia is the most preferred anaesthetic technique for elective as well as for unplanned Caesarean sections. Spinal-induced hypotension remains the most important side effect with a reported incidence between 20% and 100%. It can cause -maternal discomfort (nausea and vomiting) and impaired utero-placental perfusion. The present study was designed to examine the influence of epidural volume effect on the spread and duration of low-dose hyperbaric levobupivacaine. The aim of this study was to evaluate the influence of epidural restriction (injection of saline) on the distribution of anaesthesia as well as the incidence of hypotension during the spinal anaesthesia.After the approval by the ethics committee, 60 full-term parturient women (ASA I or II) with uncomplicated pregnancies were prospectively randomized into 2 groups: the SA group (single shot spinal anaesthesia) included 37 patients and the CSE-EVR group (combined spinal-epidural anaesthesia) included 39 patients in whom we induced the restriction of the spinal space by epidural volume compression. The blocks were performed at the L2/3 or L3/4 level in a sitting position, in the CSE-EVR group using the needle-through-needle technique. The initial dose for CSE-EVR was exactly half of the SA dose (0.5 mg per 10 cm height of hyperbaric levobupivacaine and 20 microg fentanyl). After spinal injection, an epidural catheter was located in the CSE-EVR and a volume of 20 mL saline solution injected. After injection, the women were turned supine with a left uterine displacement. Surgery was allowed when a sensory block at or above the T8 dermatome was established. We evaluated the height of the block by the pinprick method and the motor block by the Bromage scale, 10 min after spinal injection, during the operation time and at the end of surgery. Haemodynamic monitoring (NIBP, HR) was assessed every 2 min until the childbirth, then every 5 min during operative time. Anaesthetic efficacy was evaluated for breakthrough pain by visual analogue pain score (VAPS), Apgar score at birth, umbilical artery pH, and epinephrine consumption.The level of anaesthesia 10 min after the induction was significantly higher in the spinal group (SA) than in the CSE-EVR T5 (T4-T7) vs. T7 (T6-T8) group.The SA group experienced complete motor block during the time of anaesthesia, while the CSE-EVR group demonstrated significantly faster motor recovery. The incidence of hypotension and ephedrine supplementation was significantly lower in the CSE-EVR group (19 vs. 35 patients) than in the SA group (p<0.05).The neonatal outcome and umbilical artery pH were higher in the CSE-EVR group. Both groups were comparable in demographic data, VAS scores, preloading and infusion volume, atropine or ephedrine use, and adverse effects such as nausea or skin pruritus.We demonstrated a possible restriction of the spread of spinal anaesthesia by using epidural volume restriction with 20 mL saline as part of a combined spinal epidural technique. The study shows that CSE with EVR using only 50% of the levobupivacaine dose provided adequate anaesthesia for elective Caesarean delivery, as well as better maternal haemodynamic stability.

Combined Spinal-Epidural Anesthesia Using Epidural Volume Extension Leads to Faster Motor Recovery after Elective Cesarean Delivery: A Prospective, Randomized, Double-Blind Study

Combined Spinal-Epidural Anesthesia Using Epidural Volume Extension Leads to Faster Motor Recovery after Elective Cesarean Delivery: A Prospective, Randomized, Double-Blind Study