Local Anesthesia Group Research Articles

Percutaneous Endoscopic Interlaminar Lumbar Discectomy with Local Anesthesia for L5-S1 Disc Herniation: A Feasibility Study

Background: General anesthesia (GA), which is routinely applied in patients who undergo percutaneous endoscopic interlaminar lumbar discectomy (PEILD) of L5-S1 disc herniation, is closely associated with postoperative cognitive dysfunction (POCD) in the elderly. Local anesthesia (LA) is an alternative pain control protocol that has not yet been fully evaluated. Objectives: To evaluate the feasibility of LA in PEILD compared with GA. Study Design: A retrospective study. Setting: This study took place at the First Affiliated Hospital of Harbin Medical University. Methods: A total of 120 patients (aged 60-85 years) diagnosed with L5-S1 disc herniation and with American Society of Anesthesiologists fitness grade I or II between March 2016 and August 2017 were enrolled in the current study. Patients were randomly divided into LA group and GA group. For LA, 0.25% lidocaine was injected layer-by-layer into skin, subcutaneous tissue, fasciae, lumbar facet joint, muscle, and ligamentum flavum followed by injection of 1.33% lidocaine into epidural space; for GA, propofol, sufentanil, and cisatracurium were infused intravenously at 1 to 2 mg/kg, 0.3 µg/kg, and 0.15 mg/kg, respectively. Visual Analog Scale (VAS), Oswestry Disability Index (ODI), and MacNab Criteria (MNC) evaluated the feasibility of LA as pain control protocol in comparison to GA before and after operation. The development of POCD was assessed by the Mini-Mental State Examination 1 and 7 days postsurgery. Feasibility of LA as a pain control protocol was also evaluated by patient’s willingness to receive the same surgical procedure immediately and 24 hours after the surgery, and intraoperative fluoroscopy use, blood loss, surgery duration, postoperative bed confinement, and duration and cost of hospital stay were also evaluated. Results: Patients in both LA and GA groups had comparable VAS grade, ODI, and MNC preand post-PEILD, with significant pain reduction after operation. However, POCD developed only in GA group but not in LA group. In addition, compared with GA, LA group did not require postoperative bed confinement, had significantly shorter hospital stay, and lower hospital cost. Low intraoperative VAS grade and willingness to receive the same procedure reflected the acceptance of LA by patients. Limitations: The development of POCD was examined only 7 days after operation. The followup should be extended to 3 months and 2 years postoperation. Conclusions: LA has satisfactory pain control and low-risk of POCD in PEILD and is well accepted by patients. The benefits of LA are no postoperative bed confinement, faster recovery, shorter hospital stay, and lower hospital cost.

Otosclerosis surgery: Assessment of patient comfort

ObjectivesTo evaluate operative comfort and stress in patients undergoing stapedotomy for otosclerosis under local versus general anesthesia. Material and methodsConsecutive otosclerosis patients managed over a 9-month period responded to 3 validated questionnaires to assess peri- and post-operative comfort: Glasgow Benefit Inventory, Cohen's Perceived Stress Scale and the Posttraumatic Stress Disorder Checklist Scale. These results and audiometric data were compared between local and general anesthesia groups. ResultsTwenty-one patients were included in the local anesthesia group and 7 in the general anesthesia group, after exclusion of patients with history of otosclerosis surgery. There was no significant inter-group difference on Glasgow Benefit Inventory (P=0.38) or Posttraumatic Stress Disorder Checklist Scale (P=0.86). Perceived Stress Scale scores were higher in the general anesthesia group (P=0.038). In total, 67% of patients reported no discomfort under local anesthesia, and 86% were ready to undergo the procedure under local anesthesia again. There were no significant differences in postoperative symptoms, or in air-bone gap≤10dB (local anesthesia 81%, general anesthesia 71%; P=0.156). ConclusionsLocal anesthesia in otosclerosis surgery did not increase stress or postoperative symptoms compared to general anesthesia. Audiometric results were not affected by type of anesthesia.

Prospective study on the application of a WALANT circuit

HypothesisTo evaluate benefits for the patient and the economic impact for the implementation of a wide awake local anesthesia no tourniquet (WALANT) hand surgery compared to traditional major outpatient circuit. MethodsA prospective cohort study was planned comparing 150 cases of ambulatory hand surgery (carpal tunnel and trigger finger) using WALANT technique intervention out from the operating room; with another 150 which underwent intervention, outpatient setting, with preoperative evaluation, sedation and tourniquet, in the operation room (OR). Preoperative, intraoperative and postoperative pain was monitored, as well as the use of analgesics after the surgery. The resources used and costs were evaluated. Satisfaction was evaluated using a specific survey. ResultsThe pain during the surgery was equivalent for both groups and was significantly lower postoperatively for the WALANT group, with less need for the use of analgesics. Satisfaction was greater for the local anesthesia group. The use of personnel resources and hospital material was less for the WALANT group, with total saving calculated by 1,019€ per patient. SummaryProcedures such as carpal tunnel surgery and trigger finger surgery can be safely performed using wide awake surgery. Patient satisfaction is higher to conventional procedure in the OR. Pain control is excellent, especially during the postoperative period. WALANT technique for hand surgery represents a benefit for the patient in comfort, timeliness and no need for a preoperative evaluation or blood test. In addition, it represents a significant savings in hospital resources.

Transforaminal Epidural Injection of Local Anesthetic and Dorsal Root Ganglion Pulsed Radiofrequency Treatment in LumbarRadicular Pain: A Randomized, Triple-Blind, Active-Control Trial.

Lumbar radicular pain (LRP) results from inflammation and irritation of lumbar spinal nerves and the dorsal root ganglion (DRG). Our study is a prospective, triple-blind, randomized, activecontrol trial (CTRI/2016/02/006666) comparing transforaminal epidural local anesthetic (LA) injection and pulsed radiofrequency treatment of DRG in patients with chronic LRP. Patients with LRP after failed conservative management for >3months received selective diagnostic nerve root block with 1mL 2% lidocaine. Fifty patients showing positive responses were divided into groups of 25 each. The LA group received transforaminal epidural injection of 1mL 0.5% bupivacaine. The lumbar pulsed radiofrequency (LPRF) group received transforaminal epidural injection of 1mL 0.5% bupivacaine with 3 cycles of pulsed radiofrequency of the DRG for 180seconds RESULTS: Both groups were compared by observing pain intensity on a 0- to 100-point VAS and improvement in functional status by the Oswestry Disability Index (ODI version 2.0) at 2 weeks and 1, 2, 3, and 6 months. All baseline variables were comparable between the 2 groups. Statistically significant reduction in both outcomes was seen in the LPRF group compared to the LA group from 2weeks to 6months. One hundred percent of patients in the LPRF group had a ≥20- point decrease in VAS and significant percentage reduction in ODI at all time intervals up to 6 months, whereas it was seen in 80% and 28% of patients in the LA group at 3 and 6months, respectively. No complications were seen in any patients CONCLUSION: Pulsed radiofrequency of the DRG applied for longer duration results in long-term pain relief and improvement in the functional quality of life in patients with chronic LRP.

Stepwise Local Anesthesia for Percutaneous Endoscopic Interlaminar Discectomy: Technique Strategy and Clinical Outcomes

Due to suboptimal pain control under conventional local anesthesia, percutaneous endoscopic interlaminar discectomy is typically performed under general anesthesia. The purpose of this study was to develop a stepwise approach of local anesthesia for endoscopic interlaminar discectomy and evaluate its efficacy. A stepwise local anesthesia was developed, which mainly includes 3 steps: conventional local anesthesia from skin to laminae, epidural injection, and nerve root block. From June 2015 to May 2017, consecutive patients who underwent endoscopic interlaminar discectomy were included. Local anesthesia or general anesthesia was used based on patients' preference. Anesthetic effectiveness was evaluated as excellent, good, or poor, and adverse events were recorded. Hospitalization expense was compared between the 2 groups. Clinical outcomes were assessed using the Visual Analog Scale and the Oswestry Disability Index. There were 98 patients included in the study. Among them, 48 received stepwise local anesthesia and the other 50 received general anesthesia. In the stepwise local anesthesia group, 40 (83.3%) patients rated anesthetic effectiveness as excellent, 7 (14.6%) as good, and 1 (2.1%) as poor. Nine patients had complications that may be associated with local anesthesia, including dyspnea, temporary paresis of legs, and temporary worsened dysesthesia or numbness in legs. After surgery, the patients' leg pain and Oswestry Disability Index significantly improved in both groups. On average, hospitalization expense was approximately 20% less when local anesthesia was used, as compared with using general anesthesia. The stepwise local anesthesia can achieve satisfactory pain control and seems to be a good choice for endoscopic interlaminar discectomy.

Comparative study between local anesthesia and general anesthesia in the treatment of primary spontaneous pneumothorax.

There is increasing interest in non-intubated video-assisted thoracoscopic surgery (VATS). At present, this method is used in various types of thoracic surgery. Especially, simple wedge resection via VATS is thought to be an optimal indication of non-intubated VATS. This study was performed to evaluate the usefulness of VATS bullectomy under local anesthesia by comparison with bullectomy under general anesthesia. A total of 183 cases of wedge resection under general anesthesia and 52 cases of wedge resection under local anesthesia were examined. Medical records were retrospectively reviewed to assess the feasibility, usability, and cost effectiveness of wedge resection under local anesthesia. The preoperative clinical parameters, including age, sex, and the number of pneumothorax episodes and previous operations, were used to match cases and controls. There were no significant differences between the local and general anesthesia groups in operative time (57.5±23.1 and 56.6±25.6 min, respectively; P=0.857), type of operation [single-incision thoracoscopic surgery (SITS), n=48 and n=47, respectively; multi-port-VATS (M-VATS), n=4 and n=5, respectively; P=0.730], or chest tube indwelling time (3.6±1.5 and 4.4±2.5 days, respectively; P=0.064). The mean times from arrival at the operating room (OR) to skin incision (16.4±12.3 and 46.4±17.2 min, respectively; P<0.001), and from the end of surgery to arrival at the general ward (36.0±25.6 and 58.1±20.9 min, respectively; P<0.001) were significantly shorter in the local anesthesia group than the general anesthesia group. The total cost was significantly lower in the local anesthesia group than in the general anesthesia group (4,890.6±717.1 and 5,739.1±1,154.6, respectively; P<0.001). Local anesthesia shortened the overall hospital stay by reducing the interval between admission and surgery, allowing immediate ambulation after surgery. In addition, this method reduced costs by avoiding the need for anesthesia.

A comparative study of Lichtenstein hernioplasty performed under spinal anaesthesia versus local anaesthesia in treatment of unilateral inguinal hernia

Background: Lichtenstein mesh repair technique is widely used throughout the world in inguinal hernia repair. Hernioplasty done under local anaesthesia certainly has some benefits but it is yet to be proven as standard procedure. The aims of this study are to provide the data of a comparative study between Lichtenstein hernioplasties done under local versus spinal anaesthesia as well as add more data in this scenario.Methods: In this non randomized clinical study, 84 patients were selected by calculation of sample size. 42 patients were operated under spinal anaesthesia and another 42 were operated under local anaesthesia.Results: Mean duration of operation was slightly was slightly more in local anaesthesia i.e. 62.5 minutes (SD=17.8) versus 51.1 minutes (SD=21.5) in spinal anaesthesia. At 6 hours, 12 hours and 24 hours postoperative pain was significantly less in local anaesthesia group in comparison to spinal anaesthesia group with p=0.04, p=0.042, p=0.041 respectively. Postoperative complications like urinary retention, hypotension, and headache were more in spinal anaesthesia than in local anaesthesia. Duration of hospital stay was significantly less in local anaesthesia group i.e. 24.5 hours (SD=12.8) in comparison to spinal group 57.1 hours (SD=16.7).Conclusions:The study concludes that in local anaesthesia group, postoperative pain was significantly less and postoperative complications like urinary retention, headache, and hypotension were less evident compared to spinal anaesthesia. Hence the study concludes that local anaesthesia can be used as an alternative of spinal anaesthesia as a standard mode of anaesthesia for Lichtenstein hernioplasty operation.

Pain control with ultrasound-guided ilioinguinal-iliohypogastric nerve block compared with local infiltration anesthesia in patients undergoing transfemoral transcatheter aortic valve implantation: a prospective randomized trial

Introduction Ilioinguinal-ilioinguinal nerve block is frequently performed for analgesia in inguinal surgery. The authors hypothesized that preoperative ultrasound-guided ilioinguinal-iliohypogastric (II-IH) nerve block produce better intraoperative analgesia and less analgesic requirement in comparison to commonly used local infiltration anesthesia in patients undergoing transfemoral transcatheter aortic valve implantation (TF-TAVI). Methods 87 elderly patients scheduled for TF-TAVI were randomized to receive either II-IH nerve block (Group A) or local infiltration anesthesia (Group B) between July 2018 and April 2019 (ClinicalTrials.gov; ID: NCT03863899). In patients in group A ultrasound-guided II-IH nerve block was performed preoperatively by anesthesiologist. Patients in group B received local anesthetic infiltration of the operative area performed by surgeon. Pain intensity was assessed using numeric rating scale (NRS 0-10; 0 = no pain; 10 = the worth pain imaginable) in five time-points intraoperatively (femoral artery cannulation (1), aortic valve system introduction (2), aortic valve system removal (3), vessel closure devices insertion (4), the end of the operation (5)). When NRS was 4, fentanyl was given. The need for additional analgesics was also evaluated during the procedure. Results After exclusion of 10 patients the analysis was performed in 77 patients: 40 in group A and 37 patients in group B. In time points (1-4) pain intensity was lower in group A than in group B (p The need for supplementary fentanyl administration was lower in group A in comparison to group B (p = 0.02). Time from arrival in operation room to start surgery was longer in group A than in group B (median: 60 min. vs. 50 min., respectively; p = 0.01). Discussion Ultrasound-guided II-IH nerve block produce better intraoperative analgesia and less analgesic consumption than local infiltration anesthesia in patients undergoing TF-TAVI, at the cost of slightly longer patient's preparation to surgery.

Open cubital and carpal tunnel release using wide-awake technique: reduction of postoperative pain.

PurposeThis study aimed to compare the efficacy of and patient satisfaction with the wide-awake local anesthesia with no tourniquet (WALANT) technique in open cubital and carpal tunnel release surgery.MethodsFrom January 2016 to February 2017, 20 cubital tunnel syndrome (CuTS) patients were in a wide-awake (WA) group and 22 in a general (GA) anesthesia group in . Also, 20 carpal tunnel syndrome (CTS) patients were in a WA group, 22 in a local anesthesia (LA) group, and 20 in a GA group. Injection pain, perioperative pain, and postoperative pain were assessed using a 10-point pain VAS. In CuTS, functional outcome on the “quick” Disabilities of the Arm, Shoulder, and Hand questionnaire were evaluated. In CTS, subjective outcomes were assessed using the Korean version of the Michigan Hand Outcomes Questionnaire.ResultsBoth CuTS and CTS showed significant postoperative pain reduction in group WA. In CuTS, group WA had less pain than group GA up to 48 hours after surgery (P<0.05). Supplemental opioid injections were used on hospitalization day by 12% of group WA and 35% of group GA. In CTS, the postoperative VAS scores in group WA were lower during the first 24 hours than groups LA and GA (P<0.05). Opioid injections were used on hospitalization day by 5% of WA, 18% of LA, and 32% of group GA. There was no difference in postoperative functional outcomes according to anesthesia method in CuTS or CTS.ConclusionCubital and carpal tunnel surgery using the WALANT technique was comparable in function to other anesthesia methods and superior for pain. Immediate postoperative pain was much lower than other groups, which could reduce the use of opioids during hospitalization.

Estudio prospectivo sobre la aplicación de un circuito WALANT para la cirugía del síndrome del túnel carpiano y dedo en resorte

ObjectivesTo evaluate benefits for the patient and the economic impact for the implementation of a wide awake local anesthesia no tourniquet (WALANT) hand surgery compared to traditional major outpatient circuit. MethodsA prospective cohort study was planned comparing 150 cases of ambulatory hand surgery (carpal tunnel and trigger finger) using WALANT technique intervention out from the operating room; with another 150 which underwent intervention, outpatient setting, with preoperative evaluation, sedation and tourniquet, in the operation room. Preoperative, intraoperative and postoperative pain was monitored, as well as the days that required postoperative analgesia.The resources used and costs were evaluated. Satisfaction was evaluated using a specific survey. ResultsThe pain during the surgery was equivalent for both groups and was significantly lower postoperatively for the WALANT group, with less need for the use of analgesics. Satisfaction was greater for the local anesthesia group. The use of personnel resources and hospital material was less for the WALANT group, with total saving calculated by 1,019€ per patient. ConclusionsProcedures such as carpal tunnel surgery and trigger finger surgery can be safely performed using wide awake surgery. Patient satisfaction is higher to conventional procedure in the operation room. Pain control is excellent, especially during the postoperative period. WALANT technique for hand surgery represents a benefit for the patient in comfort, timeliness and no need for preoperative tests or evaluation. In addition, it represents a significant savings in hospital resources.

Combined retro-peribulbar and subconjunctival anesthesia for evisceration surgery.

To evaluate the efficacy of retro-peribulbar and subconjunctival anesthesia associated with intravenous sedation in patients undergoing evisceration and orbital implant placement. The charts of 217 patients who underwent evisceration with trans-scleral implant placement were reviewed. Midazolam and fentanyl were used for intravenous sedation. For local anesthesia, a combination of lidocaine with epinephrine and bupivacaine was injected into the retrobulbar, upper peribulbar, and subconjunctival areas. The intraoperative pain and need for supplemental anesthetic injection were recorded prospectively. The surgery was performed with local anesthesia in 116 patients (53%) and with general anesthesia in 101 patients (47%). Patients were significantly older in the local anesthesia group than in the general anesthesia group (mean age, 59.9years vs 45.2years; P < .05). Supplemental retrobulbar anesthesia was required in 5 patients (4.3%). Transition to general anesthesia was required in 1 patient (0.9%) due to severe anxiety. Orbital hemorrhage developed after retrobulbar injection in 1 patient (0.9%), but did not preclude performing evisceration. Combined retro-peribulbar and subconjunctival anesthesia with intravenous sedation can provide safe and effective intraoperative analgesia for evisceration surgery with trans-scleral implant placement.

The Effect of Intraoperative Vertebral Anesthesia on Osteoporotic Fractures Treated With Percutaneous Kyphoplasty: A Prospective Cohort Study.

A prospective randomized cohort study. The objective of this study was to investigate the effect of intraoperative vertebral anesthesia on osteoporotic vertebral compression fractures (OVCFs) when treated with percutaneous kyphoplasty (PKP). Only a few studies have evaluated the intraoperative pain reducing strategies during PKP. A total of 64 patients with OVCFs were enrolled in the study. All of the patients were randomized into 2 groups: the traditional local anesthesia group (from the skin to the periosteum, group A) and the experimental group (from the skin to a vertebral body, group B). Visual Analogue Scale (VAS) score was used to evaluate the degree of pain at six time points, that is, VAS before surgery, VAS during balloon dilation, VAS during bone cement injection, VAS soon after surgery, and VAS 12 hours and 24 hours after surgery. In addition, we noted the patients' willingness to undergo reoperation if necessary, and the variations in surgical complications between the 2 groups. There was no significant difference in VAS score before surgery between the 2 groups (t=1.694, P=0.095). The VAS scores during balloon dilatation, bone cement injection and soon after surgery were significantly different between the 2 groups (t=4.405, P=0.000; t=2.481, P=0.016; t=2.992, P=0.004, respectively). The willingness to undergo reoperation was significantly different between 2 groups (χ=6.020, P=0.049), whereas the complications showed no significant difference (χ=0.000, P=0.754). Traditional local anesthesia combined with vertebral anesthesia was effective in alleviating perioperative pain during PKP. No serious complication was noted during the operation. Level I.

Single injection pectoral nerve block (Pecs I and Pecs II) versus local anesthetic infiltration for ambulatory breast augmentation combined with monitored anesthesia care

BackgroundThis randomized, double-blind study was designed to compare single injection pectoral nerve block (Pecs I and Pecs II) versus local anesthetic infiltration for ambulatory breast augmentation under monitored anesthesia care (MAC).MethodsIn this randomized, double-blind, prospective study, 80 patients scheduled for breast augmentation under MAC using dexmedetomidine were divided into two groups. Pecs group: Ultrasound-guided pectoral nerve block was performed on both sides of the chest. Local anesthetic (LA) group: Local anesthetic infiltration was performed in the desired plane and skin incision site of each breast. The number of patients converted to general anesthesia was calculated. Postoperative pain intensity was measured using visual analog scale (VAS), and morphine consumption in the first 24 h and patient satisfaction were measured.ResultsThe success rate of the ultrasound-guided block versus local infiltration to complete surgery without conversion to general anesthesia was statistically non-significant. VAS, time of the first analgesia, and total morphine consumption were statistically significantly different between the two studied groups with significantly higher values in the LA group than Pecs group. Patient satisfaction was significantly higher in the Pecs group than in the LA group.ConclusionThe combination of Pecs blocks with MAC is helpful in patients undergoing breast augmentation.

Effects of Intradiscal Injection of Local Anesthetics on Intervertebral Disc Degeneration in Rabbit Degenerated Intervertebral Disc.

Analgesic discoblock is widely used for the diagnosis or treatment of discogenic low back pain by injecting local anesthetics. The purpose of this study was to investigate the deleterious effects of local anesthetics on degenerated rabbit intervertebral disks (IVDs) using an organotypic culture model and in vivo long-term follow-up model. To induce IVD degeneration, a rabbit annular puncture model was used. For the organotypic culture model, degenerated IVDs were harvested 1 month after the initial annular puncture and cultured for 3 or 7 days after intradiscal injection of local anesthetics (1% lidocaine and 0.5% bupivacaine). To perform in vivo analysis, local anesthetics were injected into degenerated IVDs, and IVDs were prepared for histological analysis after 6 or 12 months. In the organotypic model, terminal deoxynucleotidyl transferase dUTP nick end labeling-positive nucleus pulposus (NP) cells were significantly increased in the bupivacaine group compared with the other groups. In the in vivo study, the number of NP cells was significantly decreased in the saline and local anesthetics groups compared with the untreated control and puncture-only groups. However, there was no significant difference among the saline, lidocaine, and bupivacaine groups. In addition, histological analysis showed no significant difference of IVD degeneration among the puncture-only, saline, lidocaine, and bupivacaine groups. Although bupivacaine induced apoptotic NP cell death in the organotypic culture model, in vivo observations did not show any definitive proof to suggest that local anesthetics were capable of promoting degeneration in the degenerated IVD, except for pressurized injection-induced damage. © 2019 Orthopaedic Research Society. Published by Wiley Periodicals, Inc. J Orthop Res 37:1963-1971, 2019.

General anesthesia vs local anesthesia during mechanical thrombectomy in acute ischemic stroke

ObjectiveTo investigate the effect of general anesthesia (GA) on functional outcomes and complications rates in acute ischemic stroke (AIS) patients treated with mechanical thrombectomy (MT) compared to the use of local anesthesia (LA) at the puncture site. MethodsThis observational study was based on a prospectively registry study. AIS patients underwent MT with GA or LA from January 2013 to October 2017 were included. The primary outcome was the modified Rankin Scale (mRS) score at 90 days post-intervention. Furthermore, we assessed the long-term outcome of these patients. Multivariable logistic regression analysis was conducted to adjust for confounders. ResultsWe enrolled 187 AIS patients in this study, patients in GA group had a similar mRS score compared to LA group at 90 days (2 [IQR, 1–4] vs 2.5 [IQR, 1–4], P = .917). No differences were found in the rates of functional independence (mRS 0–2), no or minimal disability (mRS 0–1), and mortality (mRS 6) between the 2 groups at 90 days post-intervention as well as long-term follow-up. The procedure-related complications and serious adverse events were similar between the LA group and GA group (P > .05 each). In multivariable analysis, GA use was not associated with functional outcomes. ConclusionAIS patients who received GA during MT had similar functional outcomes and complications rates compared to patients received LA.

The Influence of Local Anesthesia Depth on Procedural Pain During Fluoroscopically Guided Lumbar Transforaminal Epidural Injections: A Randomized Clinical Trial.

The aim of the study was to evaluate the influence of the depth of local anesthesia application on procedural pain during lumbar transforaminal epidural steroid injection. Sixty-eight patients were enrolled who were scheduled for single-level, unilateral fluoroscopically guided lumbar transforaminal epidural steroid injection. Patients were randomly allocated to receive either subcutaneous local anesthesia (group S) or deep local anesthesia (group D) for transforaminal epidural steroid injection. The data related to pain and technical performance during the procedure was compared. In addition, the incidence of injection site soreness was assessed 2 wks after transforaminal epidural steroid injection. Sixty-seven patients completed all assessments (group S, n = 33; group D, n = 34). There was no significant difference in procedural pain and discomfort level between the groups (P = 0.151, P = 0.183, respectively). Patients in group D showed lower behavioral pain scores (P = 0.017). There was no significant difference in the numbers of needle manipulations, fluoroscopy time, and radiation dose during the procedure between the groups. Two patients in group S and three in group D complained of injection site soreness after transforaminal epidural steroid injection for a few days, but there was no significant difference in its incidence (P = 0.667). Deep local anesthesia to reduce procedural pain during transforaminal epidural steroid injection seems to have no significant clinical benefit compared with conventional subcutaneous local anesthesia. Complete the self-assessment activity and evaluation online at http://www.physiatry.org/JournalCME CME OBJECTIVES: Reduce procedural pain by considering clinical factors of the patient during fluoroscopically guided lumbar transforaminal epidural injections.Upon completion of this article, the reader should be able to: (1) Understand the potential impact of procedural pain on the performance of transforaminal epidural steroid injections; (2) Distinguish cutaneous nociceptive afferents from nociceptive afferents in muscle; and (3) Explain the factors to reduce procedural pain during fluoroscopically guided lumbar transforaminal epidural injections. Advanced ACCREDITATION: The Association of Academic Physiatrists is accredited by the Accreditation Council for Continuing Medical Education to provide continuing medical education for physicians.The Association of Academic Physiatrists designates this Journal-based CME activity for a maximum of 1.0 AMA PRA Category 1 Credit(s)™. Physicians should only claim credit commensurate with the extent of their participation in the activity.

Three Different Anesthesia Approaches in Blepharoptosis Surgery.

Despite the many methods of anesthesia for blepharoptosis, there is little documentation in the literature. When using the Müller aponeurosis composite flap advancement approach, one of the 3 anesthesia methods is chosen: general, local, and sedative anesthesia. On the other hand, the choice of anesthesia method is controversial. A total of 101 patients (48 female and 53 male) admitted to hospital for treatment were selected: 38 (37.6%) patients (49 eyes) with local anesthesia, 34 (33.7%) patients (60 eyes) with general anesthesia, and 29 (28.7%) patients (42 eyes) with sedative anesthesia. The preoperative average marginal reflex distance (MRD1) in the local, general, and sedative anesthesia groups was 0.90, 0.35, and 0.47 mm, respectively. The corneal exposure area (CEA) in the local, general, and sedative approach groups was 63.2%, 57.8%, and 55.9%, respectively. The postoperative average distance for the MRD1 was significantly different among the 3 anesthesia approaches. The postoperative MRD1 in the local approach group was 3.28 mm and the CEA improved to 75.4%. In the general anesthesia approach group, the MRD1 was 3.01 mm and the CEA was 73.4%. In the sedative anesthesia approach group, the MRD1 and CEA were 3.62 mm and 74.0%, respectively. The MRD1 in the general, local, and sedative groups was 2.65 ± 1.48, 2.39 ± 1.65, and 3.17 ± 1.77, respectively; the difference was not significant (P > 0.05). The general, local, and sedative anesthesia approaches are all effective in the correction of blepharoptosis; the results were similar regardless of the anesthesia approach. On the other hand, the patients felt more comfortable and surgeons could control the process more easily using the sedative approach.

Local Anesthetic Injections for the Short-Term Treatment of Head and Neck Myofascial Pain Syndrome: A Systematic Review with Meta-Analysis.

To evaluate the effectiveness of local anesthetic trigger point injections in adults with myofascial pain syndrome (MPS) in the head, neck, and shoulder regions compared to dry needling, placebo, and other interventions. Randomized controlled trials using local anesthetic injections in adults diagnosed with MPS were included. The Cochrane Library, MEDLINE via PubMed, Web of Science, and EMBASE libraries were searched. The primary outcome was pain measured with a 0 to 10 visual analog scale (VAS). Secondary outcomes included pain threshold, range of cervical motion, depression scale, and pressure pain intensity (PPI) score. Risk of bias was analyzed based on Cochrane's handbook. The initial search strategy yielded 324 unduplicated references up to April 1, 2018. A total of 15 RCTs were included, with 884 adult patients diagnosed with MPS. Meta-analysis showed a significant improvement in VAS pain scale of 1.585 units at 1 to 4 weeks in the local anesthetic group compared to the dry needling group (95% confidence interval -2.926 to -.245; P = .020). However, when only including double-blinded studies, the effect was not statistically significant (P = .331). There was also a significant improvement in pain of 0.767 units with local anesthetic at 2 to 8 weeks compared to placebo (95% confidence interval -1.324 to -0.210; P = .007). No statistically significant differences were found in other secondary outcomes between local anesthetic and all other interventions. Though local anesthetics provided a significant improvement in pain compared to dry needling, evidence was of low quality, and sensitivity analyses including only double-blinded studies provided no statistically significant difference. Additional studies are needed to confirm these results.

The effect of testicular torsion operation by local anesthesia

Objective To summarize the effect of testicular torsion operation by local anesthesia. Methods Retrospective analysis of 34 patients with testicular torsion in our department from Janaury 2014 to December 2016 was performed, 14 patients underwent local anesthesia (local anesthesia group), 20 patients underwent common anesthesia (common anesthesia group). The effects were evaluated by three aspects: the time from urology surgeon reception to testicular reduction and patients'pain during and after operation, and patients'satisfaction. Results Local anesthesia operation would reduce the time of testicular ischemia 15 min. There were no differences between the two groups on pa-tients'pain and satisfaction(P>0.05). Conclusions Local anesthesia orchidopexy can reduce the time of testicular ischemia, it is a better way to prevent testicular loss and to save male fertility. Key words: Spermatic Cord Torsion; Anesthesia, Local

Anesthesia type determines risk of cerebral infarction after carotid endarterectomy

ObjectiveSilent and symptomatic cerebral infarctions occur in up to 34% of patients after carotid endarterectomy (CEA). This prospective study compared the risk of new brain infarctions detected by magnetic resonance imaging (MRI) in patients with internal carotid artery stenosis undergoing CEA with local anesthesia (LA) vs general anesthesia (GA). MethodsConsecutive patients with internal carotid artery stenosis indicated for CEA were screened at two centers. Patients without contraindication to LA or GA were randomly allocated to the LA or GA group by ZIP code randomization. Brain MRI was performed before and 24 hours after CEA. Neurologic examination was performed before and 24 hours and 30 days after surgery. The occurrence of new infarctions on the control magnetic resonance images, stroke, transient ischemic attack, and other complications was statistically evaluated. ResultsOf 210 randomized patients, 105 underwent CEA with LA (67 men; mean age, 68.3 ± 8.1 years) and 105 with GA (70 men; mean age, 63.4 ± 7.5 years). New infarctions were more frequently detected on control magnetic resonance images in patients after CEA under GA compared with LA (17.1% vs 6.7%; P = .031). Stroke or transient ischemic attack occurred within 30 days of CEA in three patients under GA and in two under LA (P = 1.000). There were no significant differences between the two types of anesthesia in terms of the occurrence of other complications (14.3% for GA and 21.0% for LA; P = .277). ConclusionsThe risk of silent brain infarction after CEA as detected by MRI is higher under GA than under LA.