Nerve Block In Patients Research Articles

The efficacy of Perfusion Index for identifying failed nerve block in patients receiving upper extremity surgery: a meta-analysis.

Nerve block success is commonly assessed through a variety of techniques, including testing sensations for temperature over the relevant dermatomes and evaluating pain response (e.g., pin-prick). This meta-analysis aimed to investigate the diagnostic efficacy of Perfusion Index (PI) in identifying failed nerve blocks in patients undergoing upper extremity surgery. A literature search was conducted using four databases, including Medline (OVID), Google Scholar, EMBASE (OVID), and the Cochrane Database of Systematic Reviews, to identify relevant studies from the inception of the databases until June 2023. The main purpose of this study was to evaluate the diagnostic accuracy of PI values and PI ratios in identifying failed nerve blocks. Nine studies (published from 2006 to 2022) involving 533 participants (age ranged from 31 to 52 years) were included. The failure rate of nerve blocks ranged from 0% to 18.9%. Pooled results demonstrated promising diagnostic accuracy when using PI values as a predictor of failed nerve block (sensitivity, 77%; specificity, 88.1%; diagnostic odds ratio [DOR], 30.585). Additionally, the analysis of PI ratios as a diagnostic measure showed even higher diagnostic efficacy than using PI values alone, with a sensitivity of 82.9%, specificity of 93.1%, and DOR of 74.543. Our meta-analysis confirmed that the PI values and ratios are promising objective predictors of nerve block failure. The simplicity of these techniques supports their feasibility for routine clinical practice. Further studies focusing on different patient populations, such as pregnant women or the elderly, are needed to validate and expand upon our findings.

Puncture Site Bleeding Complications of Peripheral Nerve Block in Patients Taking Antithrombotic and Anticoagulant Drugs: An Umbrella Review.

While there are multiple guidelines for the management of bleeding complications and hematoma if being treated with antithrombotic and anticoagulant drugs, these risks are not yet stratified for procedures with regional anesthesia. This study was an umbrella review of systematic studies and meta-analysis based on PRISMA guidelines in databases of Scopus, PubMed, Medline, Cochrane Library, and Web of Science databases. Due to heterogeneity in evaluated outcomes and methods of studies, only the qualitative evidence synthesis was performed. AMSTAR checklist was used to assess the risk of bias in included systematic reviews. After an extensive search of relevant studies, 971 primary cases were identified. Following a thorough screening process, 5 systematic reviews were selected. The evidence suggests that head and neck punctures generally do not result in bleeding complications, except for rare cases of hematoma associated with Infraclavicular brachial plexus block. A deep cervical plexus block is not recommended. Interscalene blocks have varying findings, with some studies reporting hematoma incidence and spinal injury, while others consider them low risk. Supraclavicular brachial plexus block might be associated with hemothorax and infraclavicular blocks are not favored by reviews. Axillary brachial plexus blocks have a minor incidence of hematoma. Abdomen blocks, TAP blocks, ilioinguinal blocks, and rectus sheath blocks carry a higher risk of hematoma. Pectoral nerve (PECS) blocks have a relatively high risk, while paravertebral and intercostal blocks are considered high risk, but further research is needed regarding paravertebral blocks. The available evidence from systematic reviews and studies suggests varying levels of risk for different blocks and procedures that should be considered before decision-making.

The Role of Bilateral Superior Laryngeal Nerve Block in Managing Refractory Chronic Cough.

The aim was to investigate the utilization and efficacy of bilateral superior laryngeal nerve block in patients with refractory chronic cough. A retrospective chart review of 164 patients with refractory chronic cough who underwent bilateral SLN block at a single institution between November 2018 and September 2022 was performed. Demographics, comorbidities, and patient-reported outcomes including pre- and postinjection Leicester Cough Questionnaire (LCQ) scores were collected and analyzed. The cohort underwent an average of 2.97 bilateral injections (range 1-22), containing either corticosteroid and local anesthetic or corticosteroid alone. Notably, 116 of 164 of patients reported an average of 67.3% reduction in their symptoms, with the treatment effect lasting 7.60 weeks on average. The average pre- and postinjection LCQ scores were 9.70 and 13.82, respectively. A lower LCQ score represents a greater impairment of health status due to cough, and the minimum important change is 1.3 points between questionnaires. The average improvement on LCQ following bilateral SLN block was 4.11 points for this cohort. The use of in-office bilateral SLN block is an effective treatment that can be used alone or in conjunction with oral medications for the treatment of refractory chronic cough. 4 Laryngoscope, 134:1773-1777, 2024.

Ultrasound versus Nerve Stimulator Guided Obturator Nerve Block in Patients Undergoing Transurethral Resection of Bladder Tumor.

Urinary bladder cancer is more common in geriatric population. Transurethral resection of bladder tumor remains the mainstay of treatment. It is usually performed under subarachnoid block. However, obturator nerve is spared in subarachnoid block that can produce adductor jerk, which is associated with bladder injury, rupture, incomplete resection of tumor and hematoma. To overcome this jerk, selective obturator nerve block is commonly performed. Thus, we conducted this study to compare the efficacy of ultrasound and nerve stimulator-guided techniques for obturator nerve block. This is a prospective, comparative study conducted at a tertiary care hospital in Nepal. Sixty patients, scheduled to undergo Transurethral Resection of Bladder Tumor for lateral and posterolateral wall bladder cancer under subarachnoid block were enrolled and divided into two group having thirty patients in each groups. Group I received 15 ml of 0.25% Bupivacaine to block obturator nerve by using peripheral nerve stimulator. Group II received the same amount of Bupivacaine to block obturator nerve under ultrasound guidance. We evaluated the success of the block, ease of the procedure and complications. The adductor reflex was present in 23.33% of cases with nerve stimulator guided obturator nerve block, whereas, it was16.66% in ultrasound guided technique (p=0.75). The success rate of obturator nerve block was 76.66% in nerve stimulator guided technique, whereas 83.33% in ultrasound guided technique (p= 0.21). 83.33% of obturator nerve block was found to be easy in nerve stimulator guided technique, whereas 66.66 % in ultrasound guided technique (p = 0.14). There were no major complications noted. The findings of this study conclude that both ultrasound and nerve stimulator guided techniques equally abolished the adductor reflexes. Both techniques are easy to perform and safe.

The Efficacy of Scalp Nerve Block in Postoperative Pain Management after Microvascular Decompression: A Randomized Clinical Trial.

The scalp nerve block, created by injecting local anesthetics around the scalp nerves, is reported to effectively reduce pain after surgery. In this study, we evaluated the efficacy of scalp nerve block in patients with hemifacial spasm (HFS) undergoing microvascular decompression (MVD). Seventy-four patients who underwent MVD for HFS were enrolled. The block group received scalp nerve block with 0.5% ropivacaine before surgery. The primary outcome was cumulative dose of rescue analgesics 24 h postoperatively. The secondary outcomes were included pain scores, postoperative antiemetic consumption, and Quality of Recovery-15 scale. The cumulative dose of rescue analgesics at 24 h postoperatively was not significantly different between the two groups (4.80 ± 3.64 mg vs. 5.92 ± 3.95 mg, p = 0.633). However, the pain score was significantly reduced in the block group at 6, 12, and 24 h postoperatively. Postoperative antiemetic consumption was lower in the block group than the control group at 12 h. There were no significant differences between the two groups for other secondary outcomes. In MVD for HFS, a preoperative scalp nerve block might reduce postoperative pain in the early postoperative period, but a larger study using a multimodal approach is needed to confirm the efficacy of a scalp block.

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.

VAS Scores, Pain-Free Duration, Range of Motion, and IL-6 Levels are Better in Adductor Canal Block Compared to Genicular Nerve Block in Patients with Chronic Pain of Degenerative Disease of the Knee Joint

Introduction: Chronic knee pain is the leading cause of functional limitations in the older age group and accounts for many visits to health care providers. This degenerative condition is progressive with functional impairment and a severe decrease in quality of life. Pain management with Adductor Canal Block (ACB) and Genicular Nerve Block (GNB) can be an alternative treatment option for chronic knee pain. This study aims to analyze the difference between clinical & laboratory outcomes of the ACB and GNB groups. Material & Methods: An experimental study with consecutive sampling was conducted on 34 patients with chronic knee pain divided into 2 groups of ACB and GNB procedures. The parameters measured were VAS score, pain-free duration, range of motion, and interleukin-6 (IL-6) levels. Results: Predominance of chronic knee pain patients found in older women. Based on statistical analysis, there was an improvement in VAS scores (p<0,05), a similar pain-free duration (p>0,05), an improvement in the range of motion (p<0,05), and a decrease in IL-6 levels (p<0,05) significantly in the ACB group compared to GNB. Conclusion: ACB can be used as an effective therapy in treating chronic knee pain.

Prolonged blockade of the sciatic nerve in the treatment of pain in patients with chronic limb-threatening ischemia: prospective longitudinal clinical study

BACKGROUND: Systemic multimodal analgesia does not always relieve ischemic pain, and the side effects of its components may be intolerable in patients with comorbid and physically debilitation with chronic limb-threatening ischemia (CLTI). An alternative effective and safe method of pain relief for patients with CLTI is needed.
 OBJECTIVE: To evaluate the efficacy and safety of prolonged popliteal sciatic nerve block in patients with CLTI at the stages of treatment.
 MATERIALS AND METHODS: A prospective clinical study was performed in 31 patients with CLTI. Pain intensity was assessed by a numerical rating scale at the stages of treatment: (1) on admission, (2) presence of systemic multimodal analgesia (paracetamol, ketoprofen, tramadol, and morphine), (3) after catheter insertion to the popliteal sciatic nerve and prolonged nerve block with 0.5% ropivacaine solution, (4) after revascularization without anesthesia, (5) after revascularization in the presence of nerve blockade, and (6) upon discharge. Catheter insertion was performed under ultrasound control and neurostimulation. Pain intensity, frequency of insomnia, and forced lowering of the limb, need for narcotic analgesics, and patient satisfaction with treatment were assessed.
 RESULTS: Regional block before surgery provided better pain relief than systemic multimodal analgesia (p 0.001) and reduced the need for narcotic analgesics (p 0.001). Insomnia was observed less frequently with prolonged blockade of the sciatic nerve than with systemic multimodal analgesia (p 0.05), as well as forced lowering of the limb (p 0.05). Revascularization of the lower extremity has an analgesic effect; however, pain relief is required for most patients. Pain relief through sciatic nerve block at all stages of CLTI treatment, sleep normalization, and freedom from forced posture improved the quality of life and satisfaction with treatment. No complications associated with the regional blockade were recorded.
 CONCLUSION: Prolonged popliteal sciatic nerve block effectively relieves pain in patients with CLTI, is safe, and can be an alternative to systemic anesthesia.

A randomized clinical trial of glenohumeral joint steroid injection versus suprascapular nerve block in patients with frozen shoulder: a protocol for the Therapeutic Injections For Frozen Shoulder (TIFFS) study.

Frozen shoulder is a common, painful condition that results in impairment of function. Corticosteroid injections are commonly used for frozen shoulder and can be given as glenohumeral joint (GHJ) injection or suprascapular nerve block (SSNB). Both injection types have been shown to significantly improve shoulder pain and range of motion. It is not currently known which is superior in terms of relieving patients' symptoms. This is the protocol for a randomized clinical trial to investigate the clinical effectiveness of corticosteroid injection given as either a GHJ injection or SSNB. The Therapeutic Injections For Frozen Shoulder (TIFFS) study is a single centre, parallel, two-arm, randomized clinical trial. Participants will be allocated on a 1:1 basis to either a GHJ corticosteroid injection or SSNB. Participants in both trial arms will then receive physiotherapy as normal for frozen shoulder. The primary analysis will compare the Oxford Shoulder Score (OSS) at three months after injection. Secondary outcomes include OSS at six and 12 months, range of shoulder movement at three months, and Numeric Pain Rating Scale, abbreviated Disabilities of Arm, Shoulder and Hand score, and EuroQol five-level five-dimension health index at three months, six months, and one year after injection. A minimum of 40 patients will be recruited to obtain 80% power to detect a minimally important difference of ten points on the OSS between the groups at three months after injection. The study is registered under ClinicalTrials.gov with the identifier NCT04965376. The results of this trial will demonstrate if there is a difference in shoulder pain and function after GHJ injection or SSNB in patients with frozen shoulder. This will help provide effective treatment to patients with frozen shoulder.

Acupuncture for Management of Endodontic Emergencies: a Review.

Root canal treatment (RCT) employed for painful endodontic conditions like apical periodontitis and irreversible pulpitis is associated with a high incidence of postoperative pain. Pharmacological management for this purpose is effective, but not entirely free from side effects and in some cases may fail to provide adequate relief. Furthermore, concerns have been raised regarding the transmission of coronavirus disease-2019 (COVID-19) as a result of the aerosols generated and prolonged chair side time required for RCT. Acupuncture is a traditional Chinese therapy commonly employed as an alternative for the treatment of pain. And what's more, the use of acupuncture has been recently reported as treatment for the management of endodontic pain as well as on the anesthetic success in patients with irreversible pulpitis. This review aims to evaluate the current evidence for acupuncture in endodontics and its potential role in emergency pain relief and management for patients. To combat this, a thorough search for literature within the field was performed in five electronic databases. Retrieved studies were screened according to the pre-defined eligibility criteria. After both an electronic and manual search, five studies were selected for review. These studies reported the beneficial effects of acupuncture in reducing the failure of nerve block in patients with irreversible pulpitis and in controlling both intraoperative and postoperative pain following RCT. In addition, it was also reported to reduce anxiety surrounding the dental procedure and minimized the intake of analgesics after the endodontic procedure, which can result in some unwanted side effects. However, more in depth clinical research is required before any recommendation regarding the application of acupuncture in endodontic patients can be made.

A clinical study of C arm-guided selective spinal nerve block combined with low-temperature plasma radiofrequency ablation of dorsal root ganglion in the treatment of zoster-related neuralgia.

This study evaluated the analgesic efficacy and psychological response of low-temperature plasma ablation of dorsal root ganglion (DRG) combined with selective spinal nerve block in patients with acute or subacute zoster-related neuralgia (ZRN). Totally 90 ZRN patients were randomly and evenly divided into three groups. Treatment was given to Group A using C arm-guided selective spinal nerve block (C-SSVB), Group B using C-SSVB and pulsed radiofrequency (PRF), and Group C using C-SSVB and low-temperature plasma ablation of the DRG. The outcomes were examined using the Visual Analog Scale (VAS). Anxiety and depression of patients were evaluated using the Self-rating Anxiety Scale (SAS) and Self-rating Depression Scale (SDS). Quality of life was assessed using the Pittsburgh Sleep Quality Index (PSQI) and postoperative Satisfaction scale. In addition, data on adverse events and medication usage rates were collected. The 90 patients were eligible for this study. The three treatments reduced VAS scores with no significant difference between groups A and B at the same time points; however, group B tended to have numerically lower VAS scores. Comparatively, group C had significantly reduced VAS scores on day 1 and 1 month after treatment compared with the other two groups. In terms of the decreasing SAS, SDS and PSQI scores, all the three treatments improved the anxiety, depression and sleep quality of the patients. In addition, significant alleviation in anxiety was found in group C compared with group A at all- time points. However, there was no statistically significant difference among the three groups in treatment-related adverse events that mainly focused on puncture pain at the surgical-site, skin numbness and medication usage rates. C-SSVB and LTPRA of DRG will be considered as a promising treatment option for ZRN patients if those results can be confirmed after further validation.

Comparison of The Effectiveness Between Preoperative Ibuprofen Verses Placebo On the Success of the Inferior Alveolar Nerve Block in Patients with Irreversible Pulpitis

The inferior alveolar nerve block is the simplest often utilized injection procedure in dentistry, and numerous variations of the traditional nerve block have lately been reported. The dentist or surgeon must consider a variety of aspects before choosing the optimum approach, considering the treatment's effectiveness probability and potential problems. Objective: To compare the effectiveness of preoperative ibuprofen verses placebo in enhancing the success of inferior alveolar nerve block in patients with irreversibly inflamed pulp. Methods: This randomized control trial was performed for a period of 6 months. Data collection was done after taking approval from hospital ethical committee of Altamash Institute of Dental Medicine. 236 patients were included in this study. The participant was told to assess their level of discomfort after the endodontic treatment. Results: From 236 patients, the minimum age was found 18 years and maximum age was 45 years. Males were 123/236 (52.1%) while females were 113/236 (47.9%). Effectiveness of both materials was found in 74/236 (31.4%) patients. Effectiveness of materials was found significant in both groups (Ibuprofen, Placebo) having p-value 0.012. Conclusions: The effectiveness of materials was significant in both groups (Ibuprofen, Placebo). Effect modifier like age, duration of pain and gender has no significant association with effectiveness of materials.

The incidence of post amputation syndrome after pericapsular nerve group block versus sciatico-femoral nerve block in patients undergoing above knee amputation

Background & objective: Regional anesthesia for orthopedic procedures has been widely practiced around the globe, and it has been employed either alone or in combination with general anesthesia. An above knee amputation will need blockade of both femoral and sciatic nerves for successful pain control and help with peripheral sensitization for the patient. Pericapsular nerve group (PENG) block is a novel regional nerve block to provide analgesia in fractured hip patients. We assessed the effectiveness of this block compared to sciatico-femoral block and the incidence of post amputation syndrome in patients undergoing above knee amputation. Methodology: This randomized controlled single-blinded study was carried out on 30 patients with lower limb bone tumors indicated for above knee amputation admitted to surgery clinic, National Cancer Institute, Cairo University. The duration of study was from January 2021 to May 2022. Patients were randomized equally using opaque sealed envelopes into 2 groups Group A: (n = 15) pericapsular nerve group block group (PNGB) to receive 20 mL of 0.125% bupivacaine with 4 mg dexamethasone at the pubic ramus just medial to the anterior inferior iliac spine (AIIS). Group B: (n = 15) patients received sciatico-femoral block with a mixture of 20 mL 0.125% bupivacaine with 4 mg dexamethasone injected in the femoral and sciatic nerve. Postoperative VAS scores, the time to first analgesic request was and the total morphine consumed as rescue analgesic were recorded. Results: Time to first analgesic request was significantly prolonged in group B than group A (P < 0.001). Total morphine dose in first 24 h postoperative and in first 48 h postoperative were significantly lower in group B than in group A (P < 0.001 and 0.003 respectively). VAS scores were significantly lower at 2, 4 and 8 h in group B than group A (P < 0.05) and were insignificantly different at 12, 24 h, and on 2nd and 7th day between the two groups. Phantom limb syndrome frequency was significantly lower at 1, 2, 3 and 6 months in group B than in group A (P < 0.05); at 6 mo it was noted in 10 (66.67%) patients in group A and 4 (26.67%) in group B with 2.5 (1:6.23) RR (95% CI) (P = 0.028). Conclusions: Sciatico-femoral block has better outcomes than pericapsular nerve block in patients undergoing above knee amputation regarding analgesic effect and the development of phantom limb syndrome. Abbreviations: AIIS - Anterior Inferior Iliac Spine; PNGB - Pericapsular Nerve Group Block; PLP - Phantom Limb Pain; SFB - Sciatic–Femoral Nerve Block; VAS – Visual Analog Scale Key words: Above Knee Amputation; Peri Capsular Nerve Group Block; Post Amputation Syndrome; Sciatico-femoral Nerve Block Citation: Bakeer AHMH, Hussien AIH, Abd El Aziz El Shaikh SM, Soliman Idris AM. The incidence of post amputation syndrome after pericapsular nerve group block versus sciatico-femoral nerve block in patients undergoing above knee amputation. Anaesth. pain intensive care 2022;27(2):665−672; DOI: 10.35975/apic.v27i2.2356 Received: May 11, 2023; Revised: September 08, 2023; Accepted: September 17, 2023

Evaluation of Postoperative Analgesia on Addition of Dexmedetomidine to Ropivacaine 0.2% in Femoral Nerve Block in Patients undergoing Open Knee Surgery-A Randomised Single Blinded Study

Introduction: Femoral Nerve Block (FNB) renders marked postoperative analgesia in patients undergoing knee surgery and use of adjuvant to Local Anaesthetic (LA) agent is more advantageous in lengthening duration of sensory effect of block. Aim: To evaluate the effect of addition of dexmedetomidine to 0.2% Ropivacaine in FNB. Materials and Methods: The randomised clinical trial was conducted at Medical College and SSG Hospital, Vadodara, Gujarat, India which included 60 patients of either sex, American Society of Anaesthesiologists (ASA) Grade-I,II,III posted for open knee surgery. Patients were randomly allocated to two groups-Group RD patients received 0.2% ropivacaine 20 milliliter (mL) with dexmedetomidine 2 mL (50 μg) and Group R received 0.2% ropivacaine 20 mL with normal saline 2 mL for FNB. Duration of postoperative analgesia, total requirement of systemic rescue analgesic in 24 hours, vital parameters and complications were observed. Statistical analysis was done with Medcalc 14.8.1 statistical software. A p<0.05 considered as significant. Result: Duration of analgesia was significantly longer in Group RD (484±26.98 min) than in Group R (338±29.40 min), p<0.0001. Mean postoperative cumulative requirement of analgesic (Tramadol) was lesser in Group RD (207±25 milligram (mg)) than in Group R (290±30 mg), p<0.0001. Conclusion: Dexmedetomidine to ropivacaine 0.2% for FNB significantly augments duration of analgesia and reduces requirement of systemic analgesic declining its unfavourable effect.

Effect of premedication on the success of inferior alveolar nerve block in patients diagnosed with irreversible pulpitis: An umbrella review

Successful management of pain during endodontic treatment is essential for both patients and dentists. Achieving adequate pulp anesthesia in mandibular molars is a significant concern for patients with irreversible pulpitis during endodontic treatment. The increased sensitization of nociceptors due to inflammation decreases the success of inferior alveolar nerve block (IANB). The main focus is on reducing inflammation before delivery of local anesthesia to increase the success of anesthetic drugs. This umbrella review aimed to revise, qualify and summarize the existing body of evidence on the effect of premedication on IANB in patients with irreversible pulpitis. A literature search was conducted using electronic databases (PubMed, Scopus, the Web of Science, and the Cochrane Library) with no date restriction until September 2021 to identify the relevant studies. All the cross-references of the selected studies and grey literature were also screened. Four systematic reviews assessing the effect of premedication on the success of IANB were selected. A conclusion was drawn that premedication with >400 mg of ibuprofen can positively affect the success of IANB.

Ultrasound-guided thoracic paravertebral nerve block in patients undergoing radical mastectomy

Ultrasound-guided thoracic paravertebral nerve block in patients undergoing radical mastectomy

The Effect of Preoperative Naproxen Sodium on the Efficacy of Inferior Alveolar Nerve Block in Patients with Symptomatic Irreversible Pulpitis

The Effect of Preoperative Naproxen Sodium on the Efficacy of Inferior Alveolar Nerve Block in Patients with Symptomatic Irreversible Pulpitis

Primer baş ağrılı hastalarda büyük oksipital sinir blokajı ve erken dönem sonuçları

Purpose: Peripheral nerve blocks have long been used in headache treatment and greater occipital nerve (GON) blocks are the most frequently preferred peripheral nerve blocks in patients with headaches in the past years. In this study, the efficacy of GON blocks in patients with primary headache disorders was evaluated.
 Materials and Methods: This retrospective cohort study was undertaken in April 2021 and April 2022. One hundred twenty-one patients with primary headache disorders were included. Changes in the duration and frequency of headache attacks, pain severity, and type of oral medication before and after the injection treatment during the first and third months of follow-up were evaluated.
 Results: The number of headache attacks decreased from 13 to 5 and the visual analogue scale(VAS) score decreased from 9 to 5 at the end of the third month in the migraine group. Similarly, the number of headache attacks decreased from 17 to 7 and the VAS score decreased from 8 to 4 in tension-type headache (TTH) group. Improvements in all parameters were found to be statistically significant in both groups.
 Conclusion: GON block is a low-cost, rapid and minimally invasive treatment, and our data support that this method can be an effective treatment option in patients with migraine and TTH who are resistant to oral medication by reducing the number, frequency and severity of headache attacks. In conclusion, GON blockade should be considered by clinicians as a primary treatment option in patients with migraine and TTH resistant to oral medication.

Comparison of Femoral Nerve Block with Dexmedetomidine and Adductor Canal Block with Dexmedetomidine for Postoperative Analgesia for Total Knee Arthroplasty

Background : Analgesia post knee arthroplasties are crucial in early postoperative recovery and discharge . The objective of this study was to compare the analgesic efficacy of Adductor canal block with that of femoral nerve block in patients undergoing knee arthroplasties. Methods : 140 participants aged 18 years & above under American Society of Anaesthesiologists 1 and 2 physical status undergoing knee arthroplasty under spinal anaesthesia were included and were divided into 2 groups – Adductor canal block and femoral nerve block who were administered blocks under ultrasound guidance. The preoperative Visual Analog Scale score, haemodynamic variables and postoperative Visual Analog Scale scores were recorded. Results : The Visual Analog Scale scores between the two groups were not statistically significant however, a significant difference in the time taken by the Adductor canal block participants to request analgesia and to ambulate. Conclusion: Adductor canal block with Dexmedetomidine was equally efficacious when compared to Femoral nerve block with Dexmedetomidine in patients undergoing Total knee arthroplasty.

Liposomal Bupivacaine’s Effect on the Diaphragm: Comment

We read with great interest the article by Berg et al.1 about the evaluation of diaphragmatic excursion after interscalene nerve block with liposomal bupivacaine versus plain bupivacaine.In their study, the authors investigated as a primary outcome the effect of liposomal bupivacaine combined with plain bupivacaine versus plain bupivacaine alone on diaphragmatic excursion during sigh (deep) and sniff (shallow) breathing in patients undergoing total shoulder arthroscopy in the immediate postoperative period and after 24 h.1The study did not detect a difference between the two groups in absolute values of diaphragm excursion during a sigh breath at 24 h (P = 0.112), despite a greater than 1 cm difference observed. In addition, a significant difference between groups was noted in the percentage change with respect to preblock levels: –24% in the liposomal bupivacaine with bupivacaine group compared with +9% in the bupivacaine group.The authors concluded that the addition of liposomal bupivacaine to bupivacaine, in an interscalene block, results in statistically significant reductions in diaphragm excursion and pulmonary function testing 24 h after block placement compared with bupivacaine alone. The accompanying editorial underlined the need for caution in the use of liposomal bupivacaine for interscalene nerve block in patients with any pulmonary compromise.2We have two comments on this study. First, we observed that the two groups were already rather different in their baseline values, as reported in their table 2. This was particularly true for the diaphragmatic excursion (higher in the liposomal bupivacaine with bupivacaine group), the percent change of which at 24 h was the primary outcome of the study.1 The authors did not discuss this issue, but, indeed, this baseline difference might have influenced the finding of a larger percent change in diaphragmatic excursion at 24 h compared with baseline.1Second, the authors used the percentage change in diaphragmatic excursion as a measure of the level of diaphragmatic paralysis, as defined by Renes et al.,3 who proposed that a 0 to 25% reduction from baseline could be considered as no paralysis, 25 to 75% reduced could be considered as partial paralysis, and a greater than 75% reduction could be considered as complete paralysis. However, as recently reported in this journal, 24 h after interscalene nerve block, the level of diaphragmatic paralysis measured with diaphragmatic excursion may be compensated by parasternal muscle activity.4 Therefore, we believe that changes in diaphragmatic excursion alone cannot be considered as an adequate measure of diaphragmatic function.For this reason, we propose that diaphragmatic thickening fraction can be a more appropriate tool for investigating the action of medications on the diaphragm. The thickening fraction is calculated as the maximal diaphragm thickness (assessed using linear probe) during inspiration (Tdi, pi) minus the diaphragm thickness at end-expiration (Tdi, ee) divided by the Tdi, ee and multiplied by 100.5 Compared with diaphragmatic excursion, thickening fraction is a more sensitive and qualitatively accurate parameter and provides a more comprehensive measure of diaphragm contraction.Excursion of the left hemidiaphragm is more difficult to assess than the right one and this is due to interference from gastric contents and the less favorable spleen’s window. Berg et al.1 performed 13 left blocks, but they did not comment on difficulties experienced in the evaluation of the excursion of the left hemidiaphragm. In any case, use of the thickening fraction to measure and evaluate diaphragm activity would overcome this problem and should be used in the research field.Of course, we understand that standard perioperative ultrasound practice does not normally include calculating the thickening fraction, being a more difficult measure to obtain and is mostly used to assess weaning from mechanical ventilation in the intensive care unit.5 As a matter of fact, there is a bit of a schism between point-of-care ultrasound use in the operating room and intensive care settings. However, the skills required to measure thickening fraction are relatively easy to acquire under expert supervision.6In conclusion, considering the aforementioned limitations, we suggest caution in assessing the risk of adverse events in terms of diaphragmatic and pulmonary function, including dyspnea and oxygen need, with the use diaphragmatic excursion only.Dr. Cammarota declares a financial relationship with Getinge MSD (Växjö, Sweden). The other authors declare no competing interests.