Identification Of Nerve Research Articles

Role of L5 Nerve Root Morphology in Identification of Lumbosacral Transitional Vertebra. Is it a Reliable Indicator?

Objective: To determine whether L5 nerve root morphology can assist in identification Lumbosacral Transitional vertebra. Study Design: Cross sectional study. Place and Duration of Study: Radiology Department, Combined Military Hospital, Multan Pakistan, Apr 2019 to Apr 2020. Methodology: Patients of both genders, 15 to 50 years age who underwent whole spine MRI were included in the study. Patients were referred from Combined Military Hospital Multan, from neighboring Combined Military Hospitals and Civil. Sagittal and axial T1WS and T2WS were performed along with coronal T2WS/FS sequences. Axial images were assessed for identification of L5 nerve root arising from LV5-SV1 level and hence vertebra was identified as LV5. Correlation was done with sagittal images for presence of Transitional vertebra, further confirmed by counting vertebral bodies from C2 vertebra upto sacrum using cross referencing tool. Results: A total of 135 patients were included in the study. Out of these, transitional vertebra was confidently labeled in 23 patients by nerve identification method which was confirmed on vertebral counting method. However, in four patients, L5 nerve root morphology was not clear and we had to rely on vertebral counting method for identification of transitional vertebra. Conclusion: Neuroanatomy and morphology of exiting L5 nerve roots can act as a reliable method for numbering of lumbosacral vertebra and identification of transitional vertebra.

An Easy Way of Identification and Protection of the Hypoglossal Nerve during Neck Dissection for Head and Neck Cancer

Understanding the anatomical relationship between the Hypoglossal Nerve (HN) and the Facial Vein (FV) is crucial during neck dissections for head and neck cancer. The consistent placement of the HN beneath the FV provides a reliable anatomical landmark, aiding in the preservation of nerve function and reducing surgical complications. This paper reviews the anatomical pathway of the HN, its clinical implications, and surgical observations from 87 cases. Techniques for protecting the HN during neck dissection are also discussed, emphasizing the importance of precise surgical planning to avoid postoperative complications.

Nervonic acid as novel therapeutics initiates both neurogenesis and angiogenesis for comprehensive wound repair and healing.

Rapid tissue reconstruction in acute and chronic injuries are challengeable, the inefficient repair mainly due to the difficulty in simultaneous promoting the regeneration of peripheral nerves and vascular, which are closely related. Main clinical medication strategy of tissue repair depends on different cytokines to achieve nerves, blood vessels or granulation tissue regeneration, respectively. However, their effect is still limited to single aspect with biorisk exists upon long-time use. Herein, for the first time, we have demonstrated that NA isolated from Malania oleifera has potential to simultaneously promote both neurogenesis and angiogenesis in vitro and in vivo. First, NA was identified by NMR and FTIR structural characterization analysis. In a model of oxidative stress in neural cells induced by hydrogen peroxide, the cells viability of RSC96 and PC12 were protected from oxidative stress injury by NA. Similarly, based on the rat wound healing model, effective blood vessel formation and wound healing can be observed in tissue staining under NA treatment. In addition, according to the identification of nerve and vascular related markers in the wound tissue, the mechanism of NA promoting nerve regeneration lies in the upregulation of the secretion NGF, NF-200 and S100 protein, and NA treatment was also able to up-regulate VEGF and CD31 to directly promote angiogenesis during wound healing. This study provides an important candidate drug molecules for acute or chronic wound healing and nerve vascular synchronous regeneration.

A novel 3D multimodal fusion imaging surgical guidance in microvascular decompression for primary trigeminal neuralgia and hemifacial spasm

BackgroundNeurovascular compression (NVC) is a primary etiology of trigeminal neuralgia (TN) and hemifacial spasm (HFS). Despite Magnetic Resonance Tomographic Angiography (MRTA) being a useful tool for 3D multimodal fusion imaging (MFI) in microvascular decompression (MVD) surgery planning, it may not visualize smaller arterial vessels and veins effectively. We validate a novel computed tomography angiography and venography (CTA/V) - diffusion tensor tractography (DTT) -3D-MFI to enhance the MVD surgical guidance.MethodsIn this prospective study, 80 patients with unilateral primary TN or HFS who underwent MVD surgery were included. Imaging was conducted using CTA/V-DTT-3D-MFI compared with CT-MRTA-3D-MFI in predicting the responsible vessel and assessing the severity of NVC. Surgical outcomes were subsequently analyzed. Neurosurgery residents were provided with questionnaires to evaluate and compare the two approaches.ResultsCTA/V-DTT-3D-MFI significantly improved accuracy in identifying the responsible vessel (kappa = 0.954) and NVC (kappa = 0.969) compared to CT-MRTA-3D-MFI, aligning well with surgical findings. CTA/V-DTT-3D-MFI also exhibited higher sensitivity in identifying responsible vessels (98.0%) and NVC (98.7%) than CT-MRTA-3D-MFI. Additionally, CTA/V-DTT-3D-MFI showed fewer complications, shorter operation times, and lower recurrence after one year (all p < 0.05). Resident neurosurgeons emphasized that CTA/V-DTT-3D-MFI greatly assisted in formulating precise surgical strategies for more accurate identification and protection of responsible vessels and nerves (all p < 0.001).ConclusionCTA/V-DTT-3D-MFI enhances MVD surgery guidance, improving accuracy in identifying responsible vessels and NVC for better outcomes. This advanced imaging plays a crucial role in safer and more effective MVD surgery, as well as in training neurosurgeons.

Role of microscope in parotidectomy for identification and preservation of facial nerve: An institutional experience at Tertiary Care Hospital.

Objective: This study presents the authors' experience with performing parotidectomy while using the microscope and its outcomes, particularly concerning the identification and preservation of the facial nerve and its branches. Study Design: Prospective study. Setting: Tertiary Care Hospital; in Rawalpindi. Period: January 2020 to December 2023. Methods: Enrolled 70 patients with parotid lesions treated patient selection was based on the presence of parotid lesions. Data was entered and analysed by using SPSS V.26. Results: The gender distribution was 29 males (41.43%) and 41 females (58.57%), with a mean age of 38.2 years. The majority of cases involved pleomorphic adenoma, constituting 74.28% (n=52) of the total cases. Other tumor types included Warthin tumor (5.71%, n=4), monomorphic adenoma (2.86%, n=2), Mucoepidermoid carcinoma (14.29%, n=10), and adenoid cystic carcinoma (2.86%, n=2). In terms of the type of surgery performed, 82.86% (n=58) of cases underwent superficial parotidectomy, while 17.14% (n=12) underwent total conservative parotidectomy. Regarding facial nerve outcomes, temporary facial nerve paralysis was observed in 8.57% (n=6) of cases, while permanent facial nerve palsy occurred in 2.86% (n=2) of cases. Conclusion: We have seen that a microscope is a very valuable assistant in the identification and preservation of the facial nerve. Thus, we can recommend its use during the procedure in order to prevent morbidity of the patient.

Non-recurrent Laryngeal Nerve - A Rare Anatomical Anomaly that Increases the Risk of Nerve Injury during Thyroidectomy.

Nonrecurrent laryngeal nerve (NRLN), a rare anatomical variation of recurrent laryngeal nerve, is a branch of the vagus nerve (Morais M, Capela-Costa J, Matos-Lima L, Costa-Maia J (2015) Nonrecurrent Laryngeal Nerve and Associated Anatomical Variations: The Art of Prediction. Eur Thyroid J 4(4):234-238). On the right side, the prevalence of NRLN is 0.3-0.8%, while on the left side, it is extremely rare with a prevalence of 0.004%. A female in her twenties presented with thyroid swelling for 3 years with an ultrasound neck showing a TIRADS IV lesion in the left thyroid lobe. Contrast-enhanced tomography of the neck reported a lesion in the left thyroid lobe causing mass effect in the form of contralateral deviation of trachea and splaying of bilateral common carotid arteries from its common origin - probability of thyroid neoplasm along with aberrant right subclavian artery with a retroesophageal course was noted. Intraoperatively, the right laryngeal nerve was identified near its entry point in right cricothyroid joint and was traced laterally and was found to be nonrecurrent lying superior to inferior thyroid artery. Total thyroidectomy was done preserving the left recurrent laryngeal nerve and right non recurrent laryngeal nerve. NRLN should be suspected in cases with vascular anomalies based on preoperative imaging. Meticulous dissection during thyroid surgery for identification of the recurrent laryngeal nerve or NRLN is still considered to be the precise approach to avoid nerve injury.

Indocyanine Green (ICG): A Versatile Tool in Enhancing Precision in Minimally Invasive Thoracic Surgery

Intraoperative fluorescence imaging using indocyanine green (ICG) is an innovative and safe tool in minimally invasive thoracic surgery. It provides real-time imaging capabilities that can enhance surgical precision. We describe several clinical uses of ICG including intersegmental plane identification, thoracic duct injury localisation, anomalous systemic artery identification in pulmonary sequestration, phrenic nerve identification, and sentinel lymph node mapping. Successful visualisation of ICG was achieved to identify intra-thoracic anatomical structures and boundaries, allowing for safe and precise dissection.

Ultrasound-Guided Percutaneous Fasciotomies for Patients With Chronic Exertional Compartment Syndrome

Chronic exertional compartment syndrome is a well-described potential cause of leg pain in high-level athletes and soldiers. Surgical treatment of chronic exertional compartment syndrome usually involves fasciotomy, with a reported rate of complications of up to 16%, including failure of complete compartmental release and delayed return to normal daily activity, which can take up to 6 to 12 weeks. The use of a minimally invasive approach under ultrasound guidance seems to improve clinical outcomes in young active patients. We recommend the following steps for effective execution of ultrasound-guided percutaneous fasciotomy: (1) location of the compartmental fascia and identification of the superficial peroneal nerve, (2) skin incision, (3) insertion of a hook under the compartmental fascia, and (4) sectioning of the fascia.

817. ARTERIA LUSORIA: IMPLICATIONS FOR ESOPHAGEAL SURGERY

Abstract Background The aberrant right subclavian artery, also known as arteria lusoria, is an embryologic abnormality affecting 0.5-1.8% of individuals. Instead of arising from the brachiocephalic artery, the right subclavian artery emerges as the fourth branch of the aortic arch. In most cases (80%), the artery has a retro-esophageal trajectory, while in 20% it runs anteriorly, which may pose difficulties in performing a safe intra-thoracic or cervical anastomosis. This condition is associated with a non-recurrent right inferior laryngeal nerve. Methods Following Kurokawa’s publication in 2019, our unit has adopted routine recurrent bilateral laryngeal nerve lymphadenectomy in esophageal and cardia carcinomas with over than 4 cm of esophageal involvement. We present a video that features a 68-year-old male diagnosed with a squamous cell carcinoma of lower thoracic esophagus, staged as cT3N+M0. He presents with a retro-esophageal arteria lusoria and non-recurrent right inferior laryngeal nerve. Following the CROSS protocol with neoadjuvant chemoradiotherapy, the patient underwent a Mckeown esophagectomy with total thoracic lymphadenectomy. Results In this presentation, we explore the anatomical details and surgical considerations associated with the arteria lusoria in esophageal surgery. This video details the essential procedural steps for the identification of the vagus nerve and the identification of the arteria lusoria during upper mediastinal dissection. This case emphases the need for customized surgical strategies and the role of interdisciplinary collaboration, particularly integration of radiological insights. Such cooperation ensures that the surgical team is ready to address the unique challenges presented by these anatomical deviations and minimize the risks. Conclusion In conclusion, this presentation aims to highlight the procedural intricacies and the collaborative effort required to manage effectively the arteria lusoria in esophageal surgery. https://drive.google.com/file/d/1agjPmA6lxPoVVPxvgJCHaDCqs1dJP-xk/view

Identification of the suprascapular nerve with minimal volume of contrast medium: a cadaveric case study

Identification of the suprascapular nerve with minimal volume of contrast medium: a cadaveric case study

The posterolateral neck dissection: indications, planning, and techniques

The posterolateral neck dissection removes the occipital and retroauricular lymph nodes in addition to nodal groups two through five. This procedure is performed for the removal of metastatic or at-risk lymph nodes in the posterolateral neck, which most commonly originate from the cutaneous surfaces of the scalp and neck posterior to a coronal plane connecting the external auditory canals. The major surgical consideration is the identification and preservation of the spinal accessory nerve.

Characterization of the Posterior Femoral Cutaneous Nerve and Its Clinical Application for Autologous Breast Reconstruction

IntroductionAutologous breast reconstruction (ABR) uses a harvested tissue flap from the abdomen, posterior thigh, or buttocks to rebuild the breast postmastectomy. Identification of nerves for use in autologous sensate breast reconstruction flaps is an important surgical consideration as loss of breast sensation is a common risk of ABR. The posterior femoral cutaneous nerve (PFCN) and its branches supply sensory innervation to skin of the posterior thigh, leg, perineum, and buttocks, creating a feasible candidate for sensate profunda artery perforator (PAP) flaps for reestablishing breast sensation through ABR. This study characterized PFCN perforating branches located within the PAP flap region as compared to an anatomical landmark intersection (ALI). Twenty-three posterior thigh regions from 15 formalin-embalmed donors were dissected to the level of deep fascia to identify PFCN branches. PFCN branch diameter (mean, 1.34 ± 0.35 mm) and length (mean, 8.82 ± 5.78 mm) piercing the deep fascia were measured; branches were retro-dissected proximally to the PFCN trunk and the distance recorded (mean, 92.55 ± 38.00 mm). The distance to branch emergence from ALI (mean, 113.55 ± 19.80 mm) and from the midline of the posterior thigh (mean, 18.90 ± 11.17 mm) were calculated. Two-Tailed T-tests comparing the left and right limb of 7 donors determined bilateral, statistically significant difference between the length of branch emergence back to the main trunk of PFCN (P = .00). These findings illustrate the presence of adequate yet variable PFCN branches within the PAP flap region in regards to diameter, length, and location for use in sensate ABR.

Ultrasound-guided localization of the radial nerve along the humerus: providing reference points for safer upper arm surgery.

The close proximity of the radial nerve to the humerus poses a risk during upper arm surgery. Although the general course of the radial nerve is well-known, its exact position in relation to anatomical reference points remains poorly investigated. This study aimed to develop a standardized protocol for the sonographic and clinical identification of the radial nerve in the upper arm. The ultimate goal is to assist surgeons in avoiding iatrogenic radial nerve palsy. A total of 76 measurements were performed in 38 volunteers (both sides). Ultrasound measurements were performed using a linear transducer (10MHz) to identify the radial nerve at two key points: RD (where the radial nerve crosses the dorsal surface of the humerus) and RL (where the radial nerve crosses the lateral aspect of the humerus). Distances from specific reference points (acromion, lateral epicondyle, medial epicondyle, olecranon fossa) to RD and RL were measured, and the angle between the course of the nerve and the humeral axis was recorded. Humeral length was defined as the distance between the posterodorsal corner of the acromion and the lateral epicondyle. The distance from the lateral epicondyle to RD was on average 15.5cm ± 1.3, corresponding to 50% of the humeral length. The distance from the lateral epicondyle to RL was on average 6.7cm ± 0.8, corresponding to 21% of the humeral length. The course of the nerve between RD and RL showed an average angulation of 37° to the anatomical axis of the humerus. Gender, BMI, dominant hand, and arm thickness did not correlate with the distances to RD or RL. Measurements were consistent between the left and right side. The radial nerve can typically be identified by employing a 1/2 and 1/5 ratio on the dorsal and lateral aspects of the humerus. Due to slight variations in individual anatomy, the utilization of ultrasound-assisted visualization presents a valuable and straightforward approach to mitigate the risk of iatrogenic radial nerve palsy during upper arm surgery. This study introduces an easy and fast protocol for this purpose.

Navigating the void: outcomes and adaptations during parotid surgery in the absence of posterior belly of digastric muscle.

It is well known that the digastric posterior belly is one of the essential landmarks for facial nerve identification during parotid surgery. While there were multiple reports about variations of the digastric anterior belly, only a few anatomical variations of the posterior belly of the digastric muscle have been described.In this article, we describe an anatomical variation of the posterior belly of digastric muscle found during superficial parotidectomy of a patient with pleomorphic adenoma. This anatomical variation also led to an anatomical variation in the position of the facial nerve.To our knowledge, this is the first report of an absent posterior belly of digastric muscle found during live parotid surgery. The knowledge of current anatomical variation may help to avoid facial nerve injury during parotid surgery and preserve the function of muscles of facial expression.

Intraoperative fluorescence redefining neurosurgical precision.

Surgical resection is essential for treating solid tumors, with success largely dependent on the complete excision of neoplastic cells. However, neurosurgical procedures must delicately balance tumor removal with the preservation of surrounding tissue. Achieving clear margins is particularly challenging in cases like glioblastoma due to the limitations of traditional white light visualization. These limitations often result in incomplete resections, leading to frequent recurrences, or excessive resection that harms vital neural structures, causing iatrogenic nerve damage which can lead to sensory and functional deficits. Current statistics reveal a 90% recurrence rate for malignant gliomas. Similarly, an 8% incidence of iatrogenic nerve trauma contributes to an estimated 25 million cases of peripheral nerve injury globally each year. These figures underscore the urgent need for improved intraoperative techniques for lesion margin and nerve identification and visualization. Recent advances in neurosurgical imaging, such as fluorescence-guided surgery (FGS), have begun to address these challenges. Fluorescent agents used in FGS illuminate target tissues, although not all do so selectively. Despite the promising results of agents such as 5-aminolevulinic acid and indocyanine green, their applications are mainly limited by issues of sensitivity and specificity. Furthermore, these agents do not effectively address the need for precise nerve visualization. Nerve Peptide 41, a novel systemically administered fluorescent nerve-targeted probe, shows promise in filling this gap. This review assesses the major fluorescent imaging modalities in neurosurgery, highlighting each of their benefits, limitations, and potential.

The Extra-Extended Translabyrinthine Approach for Resection of Large Acoustic Neuroma: 2-Dimensional Operative Video.

The extended translabyrinthine approach to acoustic neuroma (AN) was created to allow improved visualization and access to larger tumors.1,2 The dural opening, however, remained confined to the presigmoid space. Other authors have introduced modifications to increase the dura exposure around the internal auditory canal (IAC).3-5 The extra-extended translabyrinthine approach was conceptualized by the senior author (CC) to maximize AN exposure and early cranial nerve identification. The tentorial peeling was added to allow extradural mobilization of the temporal lobe.6 This allows further safe bone removal around the IAC and petrous apex and consistent opening of the facial canal at IAC fundus. This modification creates 280-to-360-degree dura exposure at the IAC. The dural opening extends to the petrous apex superiorly and the prepontine arachnoid cistern inferiorly and includes resection of a tentorium dural flap created by the tentorial peeling.6 This exposure allows for near circumferential exposure of the tumor and early identification of the glossopharyngeal nerve in the cochlear aqueduct area, the trigeminal nerve at the porus trigeminal, and the facial nerve (FN) at IAC fundus. In addition, this ample exposure permits identification of the FN trajectory in the tumor capsule before any tumor dissection. We present a detailed video of extra-extended translabyrinthine approach technique in a patient with a large left AN (Hannover classification T4B).7 This video does not involve any human research projects not requiring Institutional Review Board/ethic committee approval. The patient consented to the procedure and to the publication of his image. Complete resection was obtained. The FN function was House-Brackman I/VI.

A non-invasive AI-based system for precise grading of anosmia in COVID-19 using neuroimaging

COVID-19 (Coronavirus), an acute respiratory disorder, is caused by SARS-CoV-2 (coronavirus severe acute respiratory syndrome). The high prevalence of COVID-19 infection has drawn attention to a frequent illness symptom: olfactory and gustatory dysfunction. The primary purpose of this manuscript is to create a Computer-Assisted Diagnostic (CAD) system to determine whether a COVID-19 patient has normal, mild, or severe anosmia. To achieve this goal, we used fluid-attenuated inversion recovery (FLAIR) Magnetic Resonance Imaging (FLAIR-MRI) and Diffusion Tensor Imaging (DTI) to extract the appearance, morphological, and diffusivity markers from the olfactory nerve. The proposed system begins with the identification of the olfactory nerve, which is performed by a skilled expert or radiologist. It then proceeds to carry out the subsequent primary steps: (i) extract appearance markers (i.e., 1st and 2nd order markers), morphology/shape markers (i.e., spherical harmonics), and diffusivity markers (i.e., Fractional Anisotropy (FA) & Mean Diffusivity (MD)), (ii) apply markers fusion based on the integrated markers, and (iii) determine the decision and corresponding performance metrics based on the most-promising classifier. The current study is unusual in that it ensemble bags the learned and fine-tuned ML classifiers and diagnoses olfactory bulb (OB) anosmia using majority voting. In the 5-fold approach, it achieved an accuracy of 94.1%, a balanced accuracy (BAC) of 92.18%, precision of 91.6%, recall of 90.61%, specificity of 93.75%, F1 score of 89.82%, and Intersection over Union (IoU) of 82.62%. In the 10-fold approach, stacking continued to demonstrate impressive results with an accuracy of 94.43%, BAC of 93.0%, precision of 92.03%, recall of 91.39%, specificity of 94.61%, F1 score of 91.23%, and IoU of 84.56%. In the leave-one-subject-out (LOSO) approach, the model continues to exhibit notable outcomes, achieving an accuracy of 91.6%, BAC of 90.27%, precision of 88.55%, recall of 87.96%, specificity of 92.59%, F1 score of 87.94%, and IoU of 78.69%. These results indicate that stacking and majority voting are crucial components of the CAD system, contributing significantly to the overall performance improvements. The proposed technology can help doctors assess which patients need more intensive clinical care.

Study on phosphonylation and modification characteristics of organophosphorus nerve agents on multi-species and multi-source albumins

Protein adducts are vital targets for exploring organophosphorus nerve agents (OPNAs) exposure and identification, that can be used to characterize the chemical burden and initiate chemical safety measures. However, the use of protein adducts as biomarkers of OPNA exposure has developed slowly. To further promote the development of biomarkers in chemical forensics, it is crucial to expand the range of modified peptides and active sites, and describe the characteristics of OPNA adducts at specific reaction sites. This study utilized multi-species and multi-source albumins as the protein targets. We identified 56 peptides in albumins from various species (including human, horse, rat and pig), that were modified by at least two OPNAs. Diverse modification characteristics were observed in response to certain agents: including (1) multiple sites on the same peptide modified by one or more agents, (2) different reactivities at the same site in homologous albumins, and (3) different preferences at the same active sites associated with differences in the biological matrix during exposure. Our studies provided an empirical reference with rationalized underpinnings supported by estimated conformation energetics through molecular modeling.We employed different peptide markers for detection of protein adducts, as (one would do) in forensic screening for identification and quantification of chemical damage. Three characteristic peptides were screened and analyzed in human albumin, including Y287ICENQDSISSK, K438VPQVS443TPTLVEVSR, and Y162LY164EIAR. Stable fragment ions with neutral loss were found from their tandem MS/MS spectra, which were used as characteristic ions for identification and extraction of modified peptides in enzymatic digestion mixtures. Coupling these observations with computer simulations, we found that the structural stability of albumin and albumin-adduct complexes (as well as the effective force that promotes stability of different adducts) changes in the interval before and after adduct formation. In pig albumin, five active peptides existed stably in vivo and in vitro. Most of them can be detected within 30 min after OPNA exposure, and the detection window can persist about half a month. These early findings provided the foundation and rationale for utilizing pig albumin as a sampling target for rapid analysis in future forensic work.

Impact of Intermittent Intraoperative Neuromonitoring (IONM) on the Learning Curve for Total Thyroidectomy by Residents in General Surgery.

Recurrent laryngeal nerve (RNL) identification constitutes the standard in thyroidectomy. Intraoperative nerve monitoring (IONM) has been introduced as a complementary tool for RLN functionality evaluation. The aim of this study is to establish how routine use of IONM can affect the learning curve (LC) in thyroidectomy. Patients undergoing total thyroidectomy performed by surgery residents in their learning curve course in 2 academic hospitals, were divided into 2 groups: Group A, including 150 thyroidectomies performed without IONM by 3 different residents, and Group B, including 150 procedures with routine use of intermittent IONM, by other 3 different residents. LC was measured by comparing operative time (OT), its stabilization during the development of the LC, perioperative complication rate. As previously demonstrated, the LC was achieved after 30 procedures, in both groups, with no differences due to the use of IONM. Similarly, there were no significant differences among the 2 groups, and between subgroups independently matched, for both OT and complications, even when comparing RLN palsy. Direct nerve visualization and IONM assessment rates were comparable in all groups, and no bilateral RLN palsy (transient or permanent) were reported. No case of interrupted procedure to unilateral lobectomy, due to evidence of RLN injury, was reported. The study demonstrates that the use of IONM thyroid surgery, despite requiring a specific training with experienced surgeons, does not particularly affect the learning curve of residents approaching this kind of surgery, and for this reason its routine use should be encouraged even for trainees.

The Safety of Peripheral Nerve Blocks: The Role of Triple Monitoring in Regional Anaesthesia, a Comprehensive Review.

Regional anaesthesia, referred to as regional blocks, is one of the most frequently used methods of anaesthesia for surgery and for pain management. Local anaesthetic drug should be administered as close to the nerve as possible. If administered too far away, this may result in insufficient block. If it is administrated too close, severe nerve damage can occur. Neurostimulation techniques and ultrasound imaging have improved the effectiveness and safety of blockade, but the risk of nerve injury with permanent nerve disfunction has not been eliminated. Intraneural administration of a local anaesthetic damages the nerve mechanically by the needle and the high pressure generated by the drug inside the nerve. In many studies, injection pressure is described as significantly higher for unintended intraneural injections than for perineural ones. In recent years, the concept of combining techniques (neurostimulation + USG imaging + injection pressure monitoring) has emerged as a method increasing safety and efficiency in regional anaesthesia. This study focuses on the contribution of nerve identification methods to improve the safety of peripheral nerve blocks by reducing the risk of neural damage.