Local Anesthetic Injection Research Articles

A preliminary study on the assessment of pain using figures among patients administered with dental local anesthesia for mandibular third molar extraction

The aim of this study was to clarify or determine any possible association between pain reports with a visual analogue scale (VAS) and a figures based scale. This research was a preliminary study aimed at developing a new pain scale without any verbal description. Healthy Japanese patients aged 20 to 39 years who received anesthetic injections for mandibular third molar extraction at our department were enrolled. Regarding pain from dental local anesthetic injections, we recorded figures selected by participants (among options of a circle, triangle, square, bar, and cross), and VAS scores. Overall, 29 men and 31 women participated in the study. Pain caused by local dental anesthesia tended to remind both men and women of the triangle among the suggested figures. Furthermore, patients who chose a cross also reported higher VAS scores than those who chose other figures. Acute pain caused by local dental anesthesia was associated with triangles, and patients who selected a cross were associated with higher VAS scores. The results of this study provide clinicians with important information for dental practice, and could prove useful in developing new pain scales.

Effect of a Local Anesthetic Injection Kit on Pain Relief and Postoperative Recovery After Transumbilical Single-Incision Laparoscopic Cholecystectomy.

This study was conducted to explore whether incisional infiltration using a local anesthetic injection kit could better relieve postoperative pain and enhance the quality of recovery compared with ultrasound-guided rectus sheath block (RSB) or conventional local anesthetic infiltration in patients undergoing transumbilical single-incision laparoscopic cholecystectomy (SILC). A total of 60 patients undergoing SILC with American Society of Anesthesiology functional status scores of I-II were randomized into the rectus sheath block group (RSB group), conventional local wound infiltration group (LAI-I group) and incisional infiltration using a local anesthetic injection kit group (LAI-II group). The primary outcomes were the patient-controlled intravenous analgesia (PCIA) demand frequency within 48 hours after the operation and postoperative pain measured by a visual analog scale (VAS) at 2 h, 4 h, 8 h, 24 h, and 48 h after surgery. Secondary outcomes were the total procedure times, cumulative consumption of anesthetic drugs, duration of surgery, duration and awaking time of anesthesia, early recovery indicator and side effects. The PCIA demand frequency in LAI-II group was significantly lower compared with patients in the RSB and LAI-I group (both P < 0.001). Moreover, the total procedure times in LAI-I and LAI-II group was significantly shorter than that in the RSB group (P < 0.001, respectively), but it was comparable between LAI-I and LAI-II group (P = 0.471). Though lower at 2h and 4h postoperative in LAI-II group, pain scores at each time point had no statistical differences among three groups. There were no significant differences among three groups for other outcomes as well. The effect of ultrasound-guided RSB and conventional local anesthetic infiltration in SILC patients were found to be similar in terms of relieving postoperative pain and promoting recovery. Incisional infiltration using a local anesthetic injection kit can significantly reduce the demand frequency of PCIA, which serves as a rescue analgesic.

Erector spinae plane block in laparoscopic colorectal surgery for reducing opioid requirement and facilitating early ambulation: a double-blind, randomized trial

Various techniques have been formulated to reduce pain and ensure early recovery after surgery, as these are major concerns among surgeons, anesthesiologists, and patients. Erector spinae plane block (ESPB), the injection of local anesthetic into the fascial plane, is a simple and novel analgesia technique widely used due to its minimal risk of complications. ESPB has been tried in various surgeries; however, no study has reported its use in colorectal surgery. This study investigated whether ESPB could promote early recovery following laparoscopic colorectal surgery (LCS) by reducing opioid consumption and pain intensity. After randomization into the ESPB or control groups, an ultrasound-guided ESPB was performed at the thoracic 10th–11th level with 40 mL of 0.25% bupivacaine or normal saline. The ESPB group used less fentanyl during the initial 24 h after surgery (P = 0.004) and experienced less pain (P < 0.05 at all-time points) than the control group. The time to the first ambulation and the length of hospital stay were shorter in the ESPB group than in the control group (P = 0.015 and P = 0.008, respectively). In conclusion, ESPB could promote early recovery by reducing opioid consumption and pain intensity in patients receiving LCS.

Assessment of the Knowledge and Management Method of Dentists in Yazd City about Ocular Complications after Injection of Local Anesthesia in Year 2021

Introduction: Local anesthesia is a routine part of all dental procedures that can cause complications. One of the most important side effects of intraoral anesthesia is ocular disorders. The aim of this study was to investigate the knowledge and proper management of dentists in Yazd City regarding ocular complications following local anesthesia injection.&#x0D; Methods: In this cross-sectional descriptive study, 193 dentists working in Yazd City were included in the study based on census sampling and they completed a questionnaire, which was consisted of two parts: demographic information and questions referring the knowledge and practice; data were analyzed using SPSS 16 software and ANOVA and T-test and Pearson correlation coefficient.&#x0D; Results: Mean knowledge score of the participantswas 1.21 ± 0. 6 with a variation range of 0 to 2. The mean awareness score of women was higher than of men, and a statistically significant difference was observed (P-value≤0.05). There was no significant relationship between awareness score and level of education, work experience and age (P-value≥0.05). Only 13.1% of general dentists and 25% of specialists had experienced ocular complications after intraoral anesthesia injection.&#x0D; Conclusion: Dentists of Yazd City had an average knowledge about ocular complications following local anesthesia injection and due to the great importance of prevention and management of ocular complications following local anesthetic injection, it seems necessary to hold retraining courses on this topic and how to manage it.

A Prospective Single-Center Brazilian Study Investigating the Efficacy and Safety of Prophylactic Phenylephrine Infusion for the Management of Hypotension During Cesarean Section Under Spinal Anesthesia.

Background Maternal hypotension occurs in up to 80% of parturients during cesarean section (CS) under spinal anesthesia. Phenylephrine, a direct-acting α-1 agonist, has been widely recommended for the prevention of hypotension. We evaluated the efficacy and safety of phenylephrine infusion to prevent hypotension in obese and non-obese patients during cesarean section. Methods One hundred forty-one patients were included in this single-arm study. Patients received prophylactic phenylephrine infusion at a rate of 50 μg/min-1 immediately after spinal local anesthetic injection until delivery.Hypotension was defined as a systolic blood pressure <100 mmHg or <20% of baseline. The primary outcome was the incidence of hypotension. Results The incidence of hypotension was 17%. The median and interquartile range (IQR) of the number of hypotensive episodes was 0 (0-0). It was observed that 79.1% of the patients had hypotension in the first six minutes. Reactive hypertension and bradycardia occurred in 20.5 and 12.7% of the patients, respectively. In addition, there was a higher incidence of bradycardia in pregnant women with a body index mass of < 30 kg/m-2.Patients with baseline systolic blood pressure <120 mmHg had a threefold increased risk of hypotension. The incidence of nausea and vomiting was 13.4 and 2.8%, respectively. The incidence of an Apgar score <7 at the first minute was 2.8%, and no neonates presented an Apgar score <7 at the fifth minute. A pH of <7.2 occurred in 6.3% of the neonates.All neonates had no sequelae and were discharged together with their mothers. Conclusion The prophylactic infusion of phenylephrine 50 μg/min-1 is safe and demonstrates efficacy in reducing maternal hypotension providing adequate maternal hemodynamic stability during CS under spinal anesthesia.

A Randomized Comparison between Classical Landmark-based and Ultrasound-guided Right Superficial Cervical Plexus Block in Attenuating Postlaparoscopic Shoulder Pain under Subarachnoid Anesthesia

ABSTRACT Background: Postlaparoscopic shoulder pain is believed to be due to phrenic nerve involvement, with an incidence of 35%–80%. Classical landmark-based right superficial cervical plexus block (SCPB) has been utilized to alleviate postlaparoscopic shoulder pain. However, there is no possibility of phrenic nerve blockade with subcutaneously deposited injectate in landmark-based SCPB. Therefore, we hypothesized that the local anesthetic injectate in the sternocleidomastoid-scalene intermuscular fascial plane under ultrasound guidance is paramount in achieving phrenic nerve blockade. The main objective was to evaluate the effect of ultrasound-guided right SCPB in decreasing postlaparoscopic shoulder pain compared to conventional landmark-guided SCPB. Methods: In this prospective randomized trial, 79 adult patients reported for laparoscopic surgeries under spinal anesthesia were randomly divided into groups; A and B. Group A patients received intermediate approach to SCPB with 10 ml of 0.5% bupivacaine under ultrasound guidance. Group B patients received SCPB using a classical landmark-based approach. The incidence of intraoperative and postoperative shoulder pain and other adverse effects were noted. Results: Intraoperative shoulder pain was significantly less in Group A than in Group B (5% vs. 43.5%, P &lt; 0.001). The postoperative shoulder pain was also significantly reduced in Group A than in Group B (5% vs. 28.2%, P = 0.013). There were no instances of major adverse effects. Conclusion: We conclude that the ultrasound-guided injectate in the sternocleidomastoid-scalene intermuscular space deeper to investing layer but superficial to the prevertebral layer of the deep cervical fascia is central to providing superior shoulder pain relief in patients undergoing laparoscopic surgery under spinal anesthesia than the classical landmark-based SCPB.

Vibrating toothbrush, ice, or topical anesthetic agent to reduce pain of local anesthetic injection in 5- to 12-year-old children undergoing dental procedures — a randomized controlled trial

BackgroundApplication of topical anesthetic agent prior to injection is the most commonly used method to control initial needle penetration pain of local anesthetic injection. Ice and vibration stimulus application are other nonpharmacologic methods used to reduce painful sensations of injection. The present study aims to verify and compare topical anesthetic, ice pretreatment, and electric toothbrush as a vibratory device, to reduce the pain of local anesthetic injections.The study was conducted on children aged 5–12 years, requiring extraction of a maxillary primary tooth. A randomized control trial design was used wherein each child was randomly assigned by permuted block randomization design method to receive either lignocaine 5% as topical anesthetic or ice pretreatment or motorized toothbrush as a vibratory device during local anesthetic injections. Sound, eye, and motor (SEM) scale was used for objective evaluation of pain during injection, and Faces Pain Scale (FPS) was used for subjective evaluation. For statistical analysis, nonparametric test — Kruskal Wallis/ANOVA test for three groups and between two groups Mann–Whitney U-test, was used to compare SEM and FPS values. Level of significance chosen was p < 0.05.ResultsSEM (palatal) and FPS (palatal) scores were slightly higher in topical anesthetic group as compared to ice pretreatment or vibration group, but the differences were not statistically significant. There were no statistically significant differences among SEM (buccal) and FPS (buccal) scores in all the three groups.ConclusionsIce cooling and electric toothbrush-induced vibration were as effective as topical anesthetic for reduction in pain due to injection.Trial registrationThe CTRI number of the trial is CTRI/2021/03/032046.

Pericapsular nerve group (PENG) block as a sole anesthetic method for malignant soft tissue excision

Since its first description by Philippe WH Peng in 2018, the Pericapsular Nerve Group (PENG) block, a novel regional anesthetic procedure, has been gaining in popularity. In order to provide appropriate analgesia, an ultrasound-guided local anesthetic injection around the hip joint is performed.We presented, in this case, the successful management of the PENG block for surgical anesthesia in the excision of a malignant soft tissue tumor in the proximal tibia of a 73-year-old female patient. Adequate sensory and motor blocks were obtained, allowing a 70-minute surgery without using additional analgesics. Postoperative pain scores were low, and the patient was discharged without complications.

Prevalence and Socio-Demographic Correlates of Dental Anxiety among a Group of Adult Patients Attending Dental Outpatient Clinics: A Study from UAE.

The aims of this paper were twofold: first, to evaluate dental anxiety levels among patients undergoing oral surgery procedures; second, to assess how dental anxiety and fear are connected to age, gender, educational background, past traumatic experiences, and the frequency of dental appointments. A cross-sectional Likert-scale questionnaire survey was conducted to collect quantitative data from 206 patients at the Oral Surgery Clinics at Dubai Dental Clinics, Dubai, United Arab Emirates. The reliability and validity of the questionnaire were tested using Cronbach's alpha. The normality of the MDAS score was tested using the Kolmogorov-Smirnov test. The chi square and Kruskal-Wallis tests were used to determine the association between categorical variables. Descriptive statistics were used to describe continuous and categorical variables. The statistical significance was set at p-value ≤ 0.05. The evaluation of the degree of dental anxiety among patients who visited the Dubai Dental clinics revealed that there was a considerably high level of moderate or high anxiety (72.3%). Tooth extraction and dental surgery procedures (95%), followed by local anesthetic injection in the gingiva (85%) and teeth drilling (70%), were the primary causes of anxiety, whereas scaling and polishing resulted in the lowest degree of anxiety (35%). There was no substantial difference in dental anxiety between male and female patients or among patients with different marital statuses. A total of 70% of patients preferred the tell-show-do method, whereas 65% chose communication strategies to reduce dental anxiety. The evaluation of the degree of dental anxiety among patients who visited Dubai Dental clinics revealed that there was a considerably high level of anxiety. Tooth extraction and dental surgery procedures, followed by local anesthetic injection and teeth drilling, were the primary causes of anxiety, whereas scaling and polishing resulted in the lowest degree of anxiety. Despite the use of a modified anxiety scale and a large and representative sample of oral surgery patients, more research is necessary to investigate the impact of various factors on dental anxiety.

Dental Pain Relief with Injectable and Topical Local Anesthetics

Dental Pain Relief with Injectable and Topical Local Anesthetics

Anterior Cervical Pain Syndromes: Defining the Patient Population and Approach to Treatments.

Objective This study aimed to evaluate patients with anterior cervical pain syndromes (ACPSs) by describing patient characteristics, therapeutic interventions, and response to treatments. Study Design This is a retrospective observational study. Methods Patients treated for diagnoses associated with ACPSs over a seven-year period in one laryngology practice at a tertiary care center were identified and evaluated via a review of clinical and surgical records. Patients identified to have undergone any treatment for ACPSs via medication, trigger-point injections of local anesthetics mixed with steroids, and/or surgical resection of the greater cornu of the hyoid bone and superior cornu of the thyroid cartilage were included. Participants subsequently underwent a medical record review and telephone interview to determine response to treatments. Results Twenty-seven patients met the inclusion criteria, including 12 patients (44.4%) with superior laryngeal neuralgia (SLN), seven patients (25.9%) with superior thyroid cornu syndrome (STCS), and eight patients (29.6%) with hyoid bone syndrome (HBS)/clicking larynx syndrome. The most common symptoms were neck/throat pain (27, 100%), globus sensation (20, 74.1%), and dysphagia (20, 74.1%). A total of 24 patients (93.3%) underwent point injections of bupivacaine and dexamethasone. Of these, 12 patients (52.2%) demonstrated a complete response that was permanent in six patients (26.1%). Seven patients (25.9%) underwent surgical intervention, with at least partial improvement noted in six patients (85.7%). Conclusion ACPSs constitute a number of complex diagnoses that remain poorly characterized in the literature. The use of point injections of local anesthetics with steroids appears efficacious with surgical options available for those with an incomplete response or return of symptoms.

Stifling the sneeze in ACHOO syndrome-What the anesthesiologist should know.

Dear Editor, A 32-year-old male, a known patient of ocular amyloidosis, was posted for superficial keratectomy (removal of the corneal epithelium up to Bowman membrane) of the right eye under topical anesthesia. This patient had a history of photic sneeze reflex (PSR) since 12 years of age and was a diagnosed case of autosomal dominant compelling helio-ophthalmic outburst (ACHOO) syndrome. This condition is characterized by uncontrollable sneezing episodes on exposure to bright light or periocular injection including peribulbar block or eyelid infiltration. He suffered from continuous sneezing episodes lasting around 5 min even in response to slit-lamp examination. This was usually followed by a refractory period during which the ophthalmic examination was conducted. He had no other systemic illness. On the day of the procedure, he developed an irrepressible sneezing reflex after cleaning and draping of the right eye in the operating room. The ambient light had stimulated the PSR. The anesthesiologist was called for help. On clinical examination, the patient’s vitals were stable with a heart rate of 62/min, SpO2 98%, and blood pressure 100/70 mmHg. His sneezing fit had ceased but the patient was extremely anxious. An intravenous line was secured and he was administered midazolam 1 mg and fentanyl 50 μg intravenously. He became calm and allowed the gentle insertion of a wire speculum but still could not look at the light of the operating microscope though there were no more sneezing episodes. He was given another 50 μg fentanyl intravenously and reassured. The procedure was completed smoothly in 10 min. No further drugs were administered nor were there any sneezing episodes. A syringe filled with injection pheniramine maleate 22.75 mg was kept ready but was not required. Five days later, he was posted for superficial keratectomy of the other eye under monitored anesthesia care. The same anesthetic technique was followed and he was administered midazolam 1 mg and fentanyl 100 μg in small aliquots even before skin preparation. The procedure was completed uneventfully under topical anesthesia without a single sneezing episode. Sneezing fit after exposure to bright light or “sun sneezing” has been reported in about 25% of the population. These patients are also prone to a sternutatory reflex after local anesthetic injection under sedation.[1] Unexpected or sudden head movement during peribulbar block or eye surgery can cause globe perforation or vascular injury and retrobulbar hemorrhage.[2] PSR is a primitive brainstem reflex, sometimes considered a variant of the trigemino-cardiac reflex with the center in the trigeminal nucleus and adjacent reticular formation. The afferent arc is from the first (ophthalmic) and second (maxillary) division of the trigeminal nerve (VN) and the efferent is the vagus nerve. A cross-talk between the optic nerve (IIN) and VN has also been hypothesized.[3] No known treatment exists except avoidance. Few authors have found deep sedation, eyelid infiltration, midazolam, and propofol to increase the risk while opioids, dexmedetomidine, and antihistamines have been found to reduce the risk.[2,4] Some have even suggested PSR as an indication for general anesthesia in ophthalmic surgery.[5] It is important for anesthesiologists routinely caring for patients for ophthalmic surgery to be aware of this reflex as it can have severe sight-threatening consequences. Financial support and sponsorship Nil. Conflicts of interest There are no conflicts of interest.

Ghost Ileostomy Release Down-Our Initial Experience

Abstract Background Many publications describe the advantages of the creation of ghost ileostomy (GI) to prevent the need for formal covering ileostomy in more than 80% of carcinoma rectum patients. However, none of the papers describes exactly how to ultimately remove the GI in these 80% of patients in whom it doesn't need formal maturation. Aim To describe and evaluate the ghost ileostomy release down (GIRD) technique in terms of feasibility, complications, hospital stay, procedure time etc. in patients with low anterior resection/ultra-low anterior resection (LAR/uLAR) with GI for carcinoma rectum. Method The present was a prospective cohort study of patients with restorative colorectal resections with GI for carcinoma rectum, Postoperatively the patients were studied with respect to ease and feasibility of the release down of GI and its complications. The data was collected, analyzed and inference drawn. Results A total of 26 patients needed the GIRD and were included in the final statistical analysis of the study. The procedure was done between 7th to 16th postoperative days (POD) and was successful in all patients without the need of any additional surgical procedure. None of the patients required any local anesthetic injection or any extra analgesics. The average time taken for procedure was 5-minutes and none of the patients had any significant difficulty in GI release. There were no immediate postprocedure complications. Conclusion The GIRD technique is a simple, safe, and quick procedure done around the 10th POD that can easily be performed by the bedside of patient without the need of any anesthesia or additional analgesics.

Evaluation of a New Method of Sciatic Nerve Block: A Prospective Pilot Study.

The location of the sciatic nerve deep within the thigh tissue makes it challenging to locate while the patient is in a supine position. The posterior intermuscular septum of the thigh, which encircles the posterior surface of the adductor magnus muscle (AMM), is where the sciatic nerve is located. Our hypothesis was that administering local anesthetic injections into this area could block the sciatic nerve. Therefore, our aim was to evaluate the effectiveness of sciatic nerve block achieved by injecting local anesthetic into the posterior intermuscular septum of the thigh, named the AMM approach. Twenty-six patients undergoing total knee arthroplasty were included in the study. We performed an ultrasound-guided sciatic nerve block by injecting 20 mL of 0.25% ropivacaine into the posterior surface of the adductor magnus muscle, using the AMM approach. Additionally, we administered a femoral nerve block with 20 mL of 0.4% ropivacaine. We assessed the sensory and motor effects of the blockade in the operated lower limb and recorded postoperative pain scores at 0, 4, 8, 12, 24, and 48 hours after the operation. The AMM approach successfully block the sciatic nerve in all 26 patients. The onset of the sensory and motor blockades was achieved within 5.4 ± 1.9 min and 8.7 ± 3.5 min, respectively. We achieved a satisfactory position with the first puncture in 19 of 26 patients (73.1%). The muscle strength of the tibialis anterior immediately after surgery was 4 (ranging from 2 to 5). Additional rescue analgesics were required in 5 of the 26 patients (19.2%) during the first 24 hours postoperatively. The AMM approach is an innovative and effective method for sciatic nerve block. When combined with simultaneous femoral nerve block in patients undergoing total knee arthroplasty, it provides a useful analgesic treatment option.

Success of the pain relief drug injections in management of the bertolloti syndrome: case report and review of the literature

Introduction: Low back pain accompanied by the lumbosacral transitional vertebra (LSTV) is called the Bertolotti syndrome. This report discussed a case treated with combined corticosteroid and local anesthetic injections based on the literature. Case report: A 35-year-old female patient was admitted to the hospital suffering from low back pain. On neurological exam, her left sacroiliac joint was painful on palpation. Her muscle strength was full, but the left patella reflex was hypoactive. X-ray images revealed “Castellvi Type IIa” LSTV on the left side; therefore, it was considered that the patient might have Bertolotti Syndrome. Because şhedid not accept surgical intervention, “betamethasone dipropionate+betamethasone sodium” and “bupivacaine hydrochloride” were injected into her bilateral sacroiliac joints, bilateral L3-4, and L4-5 facets, and left LSVT joint under fluoroscopy. Her low back pain vanished immediately after the procedure, and she was discharged from the hospital with a full recovery. With an interval of about six months, she was hospitalized 5 more times with complaints of recurrent low back pain, and at each hospitalization, "local anesthetic" (LA) alone or "local anesthetic+corticosteroid" (LA+S) combination was injected into the primary trigger zones. During long-term follow-up, she continued his daily life without any problems. Discussion: This case report showed that sequential LA and LA+S administrations could be curative for patients with Bertolotti syndrome who do not accept surgical treatment, or who cannot undergo surgical intervention. Thus, it was concluded that it would be beneficial to conduct studies with larger samples to obtain more precise information about this method.

FUNCTIONAL ANATOMY OF MANDIBULAR NERVE

The mandibular nerve is the largest branch of the trigeminal nerve. It innervates the mandibular teeth, gums, skin of the temporal region, ear, lower lip, the lower part of the face, muscles of mastication, and mucous membrane of the anterior 2/3 of the tongue. The mandibular nerve is the main pharyngeal nerve arch. The sensory and motor fibers in the mandibular nerve originate from two roots: the sensory root, which originates from the semilunar ganglion, and the motor root, which originates from the motor nucleus. The mandibular nerve has a mixture of sensory and motor nerves and motor and sensory functions. Face, cheeks and temples, oral cavity, teeth and gums, nasal cavity and sinuses, and temporomandibular joints and muscles. Trauma to the mandible can damage or tear the inferior alveolar nerve in the mandibular canal, causing sensory loss distal to the lesion. Local anesthesia of the inferior alveolar nerve is generally reserved for dental procedures. Local anesthetic injection into the oral mucosa on the medial side of the mandible can also involve the nearby lingual nerve, thus affecting the tongue and the inside of the mouth. The close connection between the submandibular canal and the lingual nerve is important in root canal infections and surgical procedures.

PO-04-185 SAFETY AND EFFICACY OF BEDSIDE ULTRASOUND-GUIDED SYMPATHETIC BLOCKADE BY PROXIMAL INTERCOSTAL BLOCK IN PATIENTS WITH ELECTRICAL STORM

Electrical storm (ES) patients (pts) who fail standard therapies have a high mortality rate. Previous studies report effective management of ES with bedside, ultrasound-guided percutaneous stellate ganglion block (SGB) as single injection or continuous infusion of local anesthetics. SGB can be technically challenging by the presence of other catheters and support devices in the anatomical area. We report our experience with sympathetic blockade administered by the regional anesthesiology team via the alternative proximal intercostal block (PICB) (Figure 1A-C). This technique targets an area typically free of catheters and support devices, and may pose less strict requirements for anticoagulation interruption, along with lower risk of focal neurologic side effects. To describe safety and efficacy of PICB in patients with refractory ES. We reviewed our institutional data on ES pts who underwent PICB between 1/2019-10/2022 to analyze procedural safety, short and long-term outcome. Total of 12 pts with ES underwent PICB during this period (Table 1). Five pts initially had left SGB, but 2/5 required PICB due to need for prolonged infusion and rotating site of infusion catheter. Three pts underwent PICB due to lack of efficacy of SGB alone. Sympathetic blockade efficacy appeared higher when left SGB was combined with PICB with response rate of 71.4%. Among ten pts who presented with recurrent ICD shocks (Figure 1D), nine had no further ICD shock after PICB until discharge, heart transplant, or death (P=0.01). There was no procedure-related complication or focal neurologic symptoms. Overall, 8 (66.7%) pts had VT ablation, 9 (75%) pts survived to discharge, 2 (16.7%) pts underwent heart transplantation, 1 (8.4%) patient had ventricular assist device implanted as a bridge to transplant, and 2 (16.7%) pts died. During median of 168 +/- 148.5 days follow up on those pts who survived to discharge without heart transplant, 71.4% remain free of any VT recurrence. In patients with refractory ES, continuous PICB provided safe and effective sympathetic block with no incidence of block-related focal neurologic symptoms. In our series, overall PICB efficacy was 66.7% and the combination of PICB and left SGB appeared complementary. The potential benefits of bilateral sympathetic blocks or block combinations should be carefully weighed against patient- and technique-specific risks and side effects. Larger studies are needed to compare these treatment techniques.

Literature Review: Pericranial Nerve Blocks for Chronic Migraines.

Headaches, especially migraines, are one of the most pervasive neurological disorders affecting up to 15.9% of the population. Current methods of migraine treatment include lifestyle changes, pharmacologic, and minimally invasive techniques such as peripheral nerve stimulation (PNS) and pericranial nerve blocks (PNB). PNBs are used to treat and prevent migraines and involves injection of local anesthetics with or without corticosteroids. PNBs include the greater occipital, supraorbital, supratrochlear, lesser occipital, auriculotemporal, sphenopalantine ganglion, and cervical root nerve blocks. Of the PNBs, the most extensively studied is the greater occipital nerve block (GONB) which has been shown to be an efficacious treatment for migraines, trigeminal neuralgia, hemi-crania continua, and post-lumbar puncture, post-concussive, cluster, and cervicogenic headaches but not medication overuse and chronic tension type headaches. In this review, we aim to summarize the recent literature on PNBs and their efficacy in the treatment of migraines including a brief discussion of peripheral nerve stimulation.

Investigating 3D-printed disk compressing against skin for pain relief in intradermal infiltration anesthesia: a randomized controlled trial

BackgroundPain intensity may be varied during the needle advancing through different skin layers, injection into the intradermal layer may exclude mixed pain from deeper planes. This study aimed to investigate whether compressing a three-dimensional (3D)-printed disk against the skin may relieve pain associated with intradermal injection of local anesthetic which mimics the skin test procedure.MethodsAfter institutional review board approval, 3D-printed disks with projections were designed for this study. Enrolled patients were randomized to receive either a disk compressing against the axillary skin during the intradermal injection of local anesthesia (compressing disk group) or an intradermal injection of local anesthesia without any compression (no compressing disk group). The primary outcomes were pain intensity (100-mm visual analog scale) and satisfaction (5-point Likert scale) as assessed by patients.ResultsNinety patients with American Society of Anesthesiologists I–II physical status receiving intradermal local anesthesia prior to an ultrasound-guided axillary approach were included. Eighty-seven patients completed the study, with 44 and 43 patients in disk and no disk groups, respectively. Pain scores were significantly different (P < 0.001) in compressing disk (median, 10; IQR, 5–20) and no compressing disk (median, 30; IQR, 20–40) groups. The median satisfaction score was 5 in both groups. No complications occurred during follow-up.ConclusionCompressing a 3D-printed disk against the skin may reduce intradermal needle pain and offers an effective alternative for nerve block induction.

EFFECTIVENESS OF MANAGING ISOLATED AVULSION FRACTURES OF PERONEUS LONGUS TENDON CONSERVATIVELY

An isolated avulsion fracture of the peroneus longus tendon is seldom seen and potentially can go undiagnosed using basic imaging methods during an initial emergency visit. If not managed appropriately it can lead to chronic pain, a reduced range of motions and eventually affect mobility. This article brings to light the effectiveness of managing such injuries conservatively.A 55 year old postman presented to clinic with pain over the instep of his right foot for 2 months with no history of trauma. Clinically the pain was confined to the right first metatarsophalangeal joint with occasional radiation to the calf. X-ray films did not detect any obvious bony injury. MR imaging revealed an ununited avulsion fracture of the base of the 1st metatarsal. The patient was subsequently injected with a mix of steroid and local anesthetic injections at the painful nonunion site under fluoroscopic guidance.Post procedure there was no neurovascular deficit. The patient was reviewed at three months and his pain score and functional outcome improved significantly. Moreover following our intervention, the Manchester Oxford Foot Questionnaire reduced from 33 to 0. At the one year follow up he remained asymptomatic and was discharged.The peroneus longus tendon plays a role in eversion and planter flexion of foot along with providing stabilization to arches of foot. The pattern of injury to this tendon is based on two factors one is the mechanism of insult, if injured, and second is the variation in the insertion pattern of peroneus longus tendon itself.There is no gold standard treatments by which these injuries can be managed. If conservative management fails we must also consider surgery which involves percutaneous fixation, or excision of the non-healed fracture fragment and arthrodesisTo conclude isolated avulsion fractures of peroneus longus tendon are rare injuries and it is important to raise awareness of this injury and the diagnostic and management challenges faced. In this case conservative management was a success in treating this injury however it is important to take factors such as patient selection, patient autonomy and clinical judgement into account before making the final decision.