Percutaneous Nerve Block Research Articles

Comparison of analgesic effects of percutaneous and transthoracic intercostal nerve block in video-assisted thoracic surgery: a propensity score-matched study

BackgroundThis study aimed to compare the analgesic efficacy of transthoracic intercostal nerve block (TINB) and percutaneous intercostal nerve block (PINB) for video-assisted thoracic surgery (VATS) using a retrospective analysis.MethodsA total of 336 patients who underwent VATS between January 2021 and June 2022 were reviewed retrospectively. Of the participants, 194 received TINB and were assigned to the T group, while 142 patients received PINB and were assigned to the P group. Both groups received 25 ml of ropivacaine via TINB or PINB at the end of the surgery. The study measured opioid consumption, pain scores, analgesic satisfaction, and safety. Propensity score matching (PSM) analysis was performed to minimize selection bias due to nonrandom assignment.ResultsAfter propensity score matching, 86 patients from each group were selected for analysis. The P group had significantly lower cumulative opioid consumption than the T group (p < 0.01). The Visual Analogue Scale (VAS) scores were lower for the P group than the T group at 6 and 12 h post-surgery (p < 0.01); however, there was no significant difference in the scores between the two groups at 3, 24, and 48 h (p > 0.05). The analgesic satisfaction in the P group was higher than in the T group (p < 0.05). The incidence of back pain, nausea or vomiting, pruritus, dizziness, and skin numbness between the two groups was statistically insignificant (p > 0.05).ConclusionThe study suggests that PINB provides superior analgesia for patients undergoing thoracic surgery compared to TINB without any extra adverse effects.

Percutaneous Peripheral Radiofrequency Ablation of Mandibular Nerve: Case Series of Seven Patients

BACKGROUND: For longer pain relief from mandibular neuralgia (MN), radiofrequency ablation (RFA) of trigeminal ganglion is undertaken intracranially and fluoroscopically. OBJECTIVES: For better safety, extracranial peripheral percutaneous mandibular nerve block (EPPMNB) has been tried; however, to the best of our knowledge, no such large series is published. STUDY DESIGN: Seven patients of MN were enrolled for EPPMNB. SETTINGS: Pain Outpatient Department (OPD) METHODS: Seven patients of MN underwent EPPMNB. RESULTS: EPPMNB can be safely undertaken in OPD with low risk of complications and is efficacious for long-term treatment for MN. LIMITATIONS: Further randomized controlled trials are required for definitive conclusions. CONCLUSIONS: EPPMNB with RFA is safe and effective for MN. KEY WORDS: Mandibular neuralgia, radiofrequency ablation, trigeminal ganglion

Percutaneous Nerve Block Catheter; A Novel Minimal Invasive Treatment for Patients with Abdominal Cutaneous Nerve Entrapment Syndrome (ACNES)

Anterior cutaneous nerve entrapment syndrome (ACNES) is a commonly overlooked [1] and ill understood cause of abdominal pain resulting in unnecessary, costly and potentially harmful diagnostic procedures. The pain is often severe and can have a debilitating effect on the patient’s quality of life.

Computed tomography guided percutaneous trans discal splanchnic nerve block for cancer pain treatment. Case report

Two cases of percutaneous transdiscal splanchnic nerve block for cancer pain treatment presented. Case 1. 50 years old man with pancreatic head and trunk cancer T4N1M0. Patients condition: intractable pain in upper abdomen during last two weeks, dysphagia, weight loss. Cholecysto-entero, gastro-entero and entero- entero anastomoses performed under epidural+general anesthesia. During 7 postoperative days pain relieved by continuous epidural anesthesia (0.2% ropivacain 5ml/hour). On postoperative day 8 epidural catheter removed due to dis lodgement. Morphine sulphate 10 mg iv injections with 4 hour intervals and cox- 2 pathway inhibitors was not sufficient for pain relief (pain score – 6-8 VAS). Splanchnic neurolysis performed on postoperative day 14. Patient laid in prone position on the computed tomography table. After marking of injection sites, definition of needles traces and deep local infiltration with 1% lidocain, two 22 gauge 20 cm Chiba needles had been inserted transdiscally on the level of T12/ L1. Pain relieved after injection of 4 ml 2% lidocaine on each side10 ml 10% aqueous phenol had been injected on each side for neurolytic block 0.1 g cefazolin injected intradiscally Patient had complete pain relief until day 5, when he felt severe continuous pain on his upper right abdomen. After two weeks of follow-up incomplete right splanchnic block diagnosed and to perform of repeated right side splanchnic neurolysis had been decided. On day 14 after 1-st neurolysis, a 3½ inch 25 gauge Quincke needle had been inserted in right retrocrural space on the level of L1. After contrast and 4ml 2% lidocaine injection, 15 ml 95% alcohol injected Pain relieved completely. No additional analgesia requirements lifetime (10 weeks). Case 2. 62 years old male with gastric cancer. Cancer recurrence after partial gastrectomy and severe intractable abdominal pain. 120 mg morphine hydrochloride daily, pain score 6-8 VAS. T12-L1 computed tomography guided transdiscal splanchnic nerve block performed in patient prone position. After marking of injection site at left side from vertebral column and deep infiltration with 1% lidocaine, a 22G 20 cm Chiba needle had been inserted. 0.1g cefazolin injected intradiscally. Intervertebral disk penetrated centrally and contrast spread was equal on both sides between aorta and L1 vertebra. Pain relieved after injection of 5 ml 2% lidocaine and 15 ml 95% alcohol. After procedure pain score – 3-4, patient was needed in 10 mg morphine hydrochloride and 150 mg lyrica daily. Computed tomography guided transdiscal splanchnic neurolysis is a safe and effective treatment tool for upper abdomen cancer pain relief. In cases of incomplete neurolysis repeated neurolytic block may be helpful.

Ultrasound-guided Glossopharyngeal Nerve Block—A New Paradigm in Pain Management

AbstractWe report eight cases of oropharyngeal carcinoma in which ultrasound-guided percutaneous distal glossopharyngeal nerve (GPN) block was performed for pain relief. Mean age of the patients was 52 ± 11.5 [SD] years and median baseline pain score was 7 (IQR, 5–8). Under ultrasound guidance, mixture of ropivacaine and dexamethasone was injected into parapharyngeal space. Pain reduced after four weeks in all patients (median [IQR], 4 [2.5–5]). Median quality of life score improved as compared with baseline in physical health (63 [44–69] vs 50 [44–63]) and psychological domains (56 [56–63] vs 50 [50–63]), reduced in social relationships domain (31 [19–44] vs 44 [31–44]), remained same in environment domain (56 [44–69] vs 56 [56–56]). Seven patients showed improvement on Patients' Global Impression of Change scale, while six showed improvement on Clinical Global Impressions scale. These early results show that ultrasound guided distal GPN block can reduce pain intensity in oropharyngeal carcinoma patients.

SY28-2 Interventional radiology for palliation of cancer pain

Interventional radiology (IR) is a minimally-invasive treatment applicable for palliation of various symptoms of the cancer patients. IR procedures for the patients with cancer pain, which provide direct approach to the responsible anatomical area originating pain, include percutaneous osteoplasty, nerve block, and transcatheter arterial embolization (TAE). Those procedures have been used for many years; however, they are not fully-utilized in the clinical practice of palliative care mainly because of the paucity of evidence and lack of awareness and readiness of the access to the IR specialists.

Cadaveric Evaluation of Injectate Distribution for Two Maxillary Nerve Block Techniques in Cats.

Regional nerve blocks have been shown to decrease general anesthetic drug requirements and improve pain management in patients undergoing surgery. Regional nerve blocks are used routinely in patients undergoing oral surgery, such as dental extractions. There is little published information regarding the efficacy of feline maxillary and infraorbital nerve blocks. The goal of the study was to compare injectate distributions of the infraorbital foramen and percutaneous maxillary nerve block techniques in feline cadavers using a combined dye and radiopaque contrast media solution to simulate an injection. There was no significant difference in length of stained nerve between the two different techniques. It was not necessary to advance the needle into the infraorbital canal to achieve effective staining of the maxillary nerve. There was no significant difference in injectate distribution between two different injectate volumes, 0.2 and 0.4 ml, indicating that the smaller volume injected at the infraorbital foramen resulted in adequate nerve staining.

Clinical Outcome of Percutaneous Trigeminal Nerve Block in Elderly Patients in Outpatient Clinics.

ObjectiveTrigeminal neuralgia (TN) is a severe neuropathic condition that affects several elderly patients. It is characterized by uncontrolled pain that significantly impacts the quality of life of patients. Therefore, the condition should be treated as an emergency. In the majority of patients, pain can be controlled with medication; however, other treatment modalities are being explored in those who become refractory to drug treatment. The use of the trigeminal nerve block with a local anesthetic serves as an excellent adjunct to drug treatment. This technique rapidly relieves the patient of pain while medications are being titrated to effective levels. We report the efficacy and safety of percutaneous trigeminal nerve block in elderly patients with TN at our outpatient clinic. MethodsTwenty-one patients older than 65 years with TN received percutaneous nerve block at our outpatient clinic. We used bupivacaine (1 mL/injection site) to block the supraorbital, infraorbital, superior alveolar, mental, and inferior alveolar nerves according to pain sites of patients. ResultsAll patients reported relief from pain, which decreased by approximately 78% after 2 weeks of nerve block. The effect lasted for more than 4 weeks in 12 patients and for 6 weeks in two patients. There were no complications. ConclusionPercutaneous nerve block procedure performed at our outpatient clinic provided immediate relief from pain to elderly patients with TN. The procedure is simple, has no serious side effects, and is easy to apply.

Transient obturator nerve block with fascia iliaca compartment block following local infiltration for open inguinal herniorrhaphy

BackgroundIlioinguinal nerve block is effective for analgesia after open inguinal herniorrhaphy. However, transient femoral nerve palsy can happen after the block. The ambulatory patients sometimes cannot discharge from the hospital with the motor deficiency. Here is described a case of fascia iliaca compartment block with complete obturator nerve block after surgical infiltration analgesia for open inguinal herniorrhaphy.Case presentationAn ambulatory open inguinal herniorrhaphy was performed for a 63-year-old male under general anesthesia. The mixture of short-/long-acting local anesthetics was injected by the surgeon into the subcutaneous tissue, between the Camper’s and Scarpa’s fasciae, into the inguinal canal, and between the internal oblique and transversus abdominis muscles. The patient could not adduct his ipsilateral hip joint at all 1 h after emergence. The flexion of the hip joint was weakened two more hours later, and numbness of the lateral thigh emerged. The complications completely resolved 7 h after surgery.ConclusionsSurgical infiltration analgesia as well as percutaneous ilioinguinal nerve block can cause both fascia iliaca plane block and obturator nerve block. Analgesia regimen should be carefully built for ambulatory surgery.

Patient with residual pleural space and air leak after right lower lobectomy undergoing percutaneous phrenic nerve block

Patient with residual pleural space and air leak after right lower lobectomy undergoing percutaneous phrenic nerve block

Network meta-analysis of percutaneous vertebroplasty, percutaneous kyphoplasty, nerve block, and conservative treatment for nonsurgery options of acute/subacute and chronic osteoporotic vertebral compression fractures (OVCFs) in short-term and long-term effects.

Background:Osteoporotic vertebral compression fractures (OVCFs) commonly afflicts most aged people resulting back pain, substantial vertebral deformity, functional disability, decreased quality of life, and increased adjacent spinal fractures and mortality. Percutaneous vertebral augmentation (PVA) included percutaneous vertebroplasty (PVP) and percutaneous kyphoplasty (PKP), nerve block (NB), and conservative treatment (CT) are used for the nonsurgery treatment strategy of OVCFs, however, current evaluation of their efficacy remains controversial.Methods and analysis:A systematic literature search was carried out in PubMed, EMBASE, Web of Knowledge, and the Cochrane Central Register of Controlled Trials up to October 31, 2017. Randomized controlled trials (RCTs) were compared PVP, PKP, NB, or CT for treating OVCFs. The risk of bias for each trial was rated according to the Cochrane Handbook. Mean differences (MDs) with 95% confidence intervals (CIs) were utilized to express VAS (visual analog scale) outcomes. The network meta-analysis (NMA) of the comparative efficacy measured by change of VAS on acute/subacute and chronic OVCFs was conducted for a short-term (<4 weeks) and long-term (≥6–12months) follow-up with the ADDIS software.Results:A total of 18 trials among 1994 patients were included in the NMA. The PVA (PVP and PKP) had better efficacy than CT. PKP was first option in alleviating pain in the case of the acute/subacute OVCFs for long term, and chronic OVCFs for short term and long term, while PVP had the most superiority in the case of the acute/subacute OVCFs for short term. NB ranks higher probability than PKP and PVP on acute/subacute OVCFs in short and long-term, respectively.Conclusions:The present results suggest that PVA (PVP/PKP) had better performance than CT in alleviating acute/subacute and chronic OVCFs pain for short and long-term. NB may be used as an alternative or before PVA, as far as pain relief is concerned. Various nonsurgery treatments including CT, PVA (PVP/PKP), NB, or a combination of these treatments are performed with the goal of reducing pain, stabilizing the vertebrae, and restoring mobility.

Effect of the pretreatment of nalbuphine pretreatment combined with ultrasound-guided paraspinal nerve block on the cellular immune function of the patients with lung cancer under thoracoscopic surgery

Objective Based on the study on the effect of the nalbuphine pretreatment combined with ultrasound-guided paraspinal nerve block on the cellular immune function of the patients with lung cancer undergoing thoracoscopic surgery, to evaluate the optimization effect of the nalbuphine pretreatment combined with ultrasound-guided percutaneous nerve block. Methods Sixty patients with lung cancer undergoing thoracoscopic surgery. Age 40-70 year. Weight 55-80 kg. America society of Anesthesiologists score standard (ASA) class Ⅰ or Ⅱ. TNM stage stage Ⅰ or Ⅱ. Use a random number table method. The patients were randomly divided into 3 groups (n=20): Control group (group A), nalbuphine pretreatment group (group B), nalbuphine pretreatment + Ropivacaine group (group C). After entering the operating room group C after the local anesthesia was blocked anesthesia guided by ultrasound-guided in the surgical side of T4, T7 and T9 at the root of the transverse process. Inject 0.5% ropivacaine 10 ml per point. The anesthesia induction was initiated after the block plane was determined. Before the induction of general anesthesia, the group B and group C were injected nalbuphine 20 mg intravenously. as the same way, group A was injected equal volume physiological saline. The anesthesia was maintained by two-channel target using remifentanil and propofol.5 min before anesthesia induction (T0), 1 h after surgery (T1), when the surgery finished (T2), and 24 hours after the surgery finished (T3). Take the central vein blood sample. To detect the concentration of the norepinephrine (NE), epinephrine (E) and cortisol (Cor) and the T lymphocyte subgroup CD3+ , CD4+ , CD8+ level and CD4+ /CD8+ ratio in the T0-T3 plasma. Record the dosage of propofol, remifentanil and the utilization rate of vasoactive drug in the convalescent period. Results Compared with T0, the cell level of CD3+ : 50.6±6.0, CD4+ : 28.4±6.2 and the ratio of CD4+ /CD8+ : 1.3±0.1 were decreased in group A at T2, and the cell level of CD3+ : 40.5±5.1, CD4+ : 27.3±6.4 and the ratio of CD4+ /CD8+ : 1.8±0.3 were decreased in group A at T3, the cell levels of CD3+ : 54.4±6.0and CD4+ : 32.5±6.9 were decreased in group B at T2, the cell levels of CD3+ : 52.3±5.7and CD4+ : 38.7±7.6 were decreased in group B at T3, the cell levels of CD3+ : 63.3±7.5 and CD4+ 3: 8.2±7.0 were decreased in group C at T2, the cell levels of CD3+ : 60.4±7.4and CD4+ : 42.5±7.4 were decreased in group C at T3 (P=0.000); Compared with group A, the cell level of CD3+ and CD4+ were increased in group B, C at T2 and T3 (ibid), the ratio of CD4+ /CD8+ : 1.9±0.1 was increased in group B at T2, CD4+ /CD8+ : 2.1±0.2 at T3, the ratio of CD4+ /CD8+ : 2.2±0.2 was increased in group C at T2, CD4+ /CD8+ : 2.2±0.2 at T3 (P=0.000); Compared with group B, the cell level of CD3+ , CD4+ and the ratio of CD4+ /CD8+ were increased in group C at T2 and T3 (ibid) (P=0.000). Compared with group A and B, the concentration of the norepinephrine (NE), epinephrine (E), cortisol (Cor) and the dosage of propofol, remifentanil in the period of the surgery and the utilization rate of vasoactive drug in the convalescent period were decreased in group C at T1-T3; Compared with group A, the concentration of the norepinephrine (NE), epinephrine (E), cortisol (Cor) and the dosage of propofol, remifentanil in the period of the surgery and the utilization rate of vasoactive drug in the convalescent period were decreased in group B at T1-T3. Conclusion The pretreatment of nalbuphine pretreatment combined with ultrasound-guided paraspinal nerve block can improve the the cellular immune function of the patients with lung cancer under thoracoscopic surgery. Key words: Nalbuphine; Nerve block; Immunity cells; Thoracoscopy; Lung cancer

Radiofrequency ablation of bilateral splanchnic nerve in acute pancreatitis pain: Interventional approach.

Sir, Radiofrequency ablation (RFA) of the bilateral splanchnic nerve has been used in patients with chronic pancreatitis pain refractory to medical management.[1] We describe the management of pain in acute pancreatitis using RFA ablation of bilateral splanchnic nerve. A 37-year-old male presented with chief complaints of severe pain abdomen radiating to back and vomiting since 6-months. The pain aggravated following meals and was not relieved with analgesics. The verbal numeric rating scale (VNRS)[2] was 9/10. Patient was chronic alcoholic since 25 years. Blood investigations were within acceptable range. Computed tomography (CT) of the abdomen showed bulky and heterogeneous pancreas with necrosis (>50%) in body and tail of pancreas sparing the head region [Figure 1a] with modified CT severity index of 10. A large collection 9 cm × 6 cm was present in the lesser sac, which was managed with the ultrasound-guided aspiration of a pseudocyst. The patient showed clinical improvement, but the VNRS continued to be 8/10 in spite of analgesics. Patient had received several trials of the combination of analgesics including; paracetamol, tramadol, paracetamol-codeine phosphate combination, tapentadol, flupirtine, and adjuvant medications like pancreatic enzyme supplementation, with no relief in symptoms. A CT scan done after 4 weeks revealed a bulky pancreas with heterogeneous density with modified CT severity index of 6 for which no surgical intervention was required. Patient was referred to a pain clinic. After explaining the procedure to the patient and written informed consent, RFA of bilateral splanchnic nerve was planned. An intravenous access (IV) was placed and 1 L normal saline was administered. Monitoring (Aestiva 5™, GE healthcare, Datex-Ohmeda division, Helsinki, Finland) was started and IV fentanyl 50 μg and diclofenac 50 mg were administered to reduce pain related to the prone position. Under strict asepsis and fluoroscopic guidance a 20G, 10 cm RF needle with 10 mm curved active tip (Cosman cannula RFK™ Cosman Medical, Inc., Burlington, MA, USA) was placed at the junction of anterior one-thirds and posterior two-thirds of T11 vertebral body [Figure 1b] and after confirmation with nonionic radio-opaque contrast, sensory stimulation was confirmed at 50-Hz frequency and at 0.5 V [Figure 1c]. Following no motor stimulation, RFA was done at 60°C, and four cycles of 120 s each were applied. A mixture of 5 ml of 0.2% ropivacaine and 20 mg of triamcinolone was injected before removing the RF needle. A similar procedure was done on the other side. The patient's VNRS reduced to 0/10. At 1-year, VNRS remained 2/10 with improvement in quality of life and occasional requirement of mild analgesics.Figure 1: (a) Computed tomography of the abdomen, the white arrow showing necrosis of body and black arrow showing necrosis in the tail of pancreas (b) fluoroscopic image of radio frequency needle placed at the junction of anterior one-thirds and posterior two-thirds of T11 vertebral body (c) splanchnic nerve block with radio frequency needle and stimulating electrode in situPain in acute pancreatitis is transmitted via afferent splanchnic nerves of the celiac plexus.[34] Percutaneous splanchnic nerve block was performed in the present case as compared to celiac plexus block due to its predictable anatomy, accurate needle placement, and theoretically reduced the risk of complications. Under fluoroscopy, RFA is a minimally invasive target-selective technique, which heats the tissues at 65-75°C to produces thermal lesion. This interrupts the conduction of nociceptive signals and blocks the pain transmission. The duration of pain relief depends on the duration of time taken by coagulated nerves to regenerate.[5] Earlier authors had also reported a reduction in the pain after RFA in patients with chronic pancreatitis.[67] Pain during acute pancreatitis offers more challenges, as patients are clinically less stable than in chronic pancreatitis. Prone position may require additional analgesics due to discomfort and pain during RFA procedure.[5] Application of bilateral splanchnic nerve RFA may be considered for pain relief in moderately severe acute pancreatitis. Financial support and sponsorship Nil. Conflicts of interest There are no conflicts of interest.

Perineural bupivacaine injection reduces inguinodynia after inguinal hernia repair

Inguinodynia, defined as pain lasting >3months after inguinal hernia repair, remains the major complication of hernia operation. We sought to determine the effect of direct perineural infiltration on acute pain and inguinodynia after open inguinal hernia repair. Patients who presented with an inguinal hernia at a university teaching hospital were evaluated prospectively and randomized to either (1) percutaneous ilioinguinal nerve block or (2) percutaneous ilioinguinal nerve block with additional perineural infiltration of the ilioinguinal, iliohypogastric, genitofemoral nerves. All patients in each group received a total of 12mL of 0.5% bupivacaine. Self-reported faces of pain level (1-10), minutes to discharge from the recovery room, narcotic quantity consumed (oxycodone 5 mg/paracetamol 325 mg), days on narcotics, and incidence of inguinodynia at 3months were all recorded. Ninety-two patients were randomized in the study. Patients who received perineural bupivacaine infiltration of nerves had less recovery room pain (1.3 vs 3.9, P<.001) and shorter recovery discharge times (89 vs 105min, P=.047) and consumed fewer narcotics (9.7 vs 15.1 doses, P=.010). The incidence of inguinodynia at 3months was less in the treatment group (8.2% vs 27.9%, P=.013). We have implemented a novel and inexpensive method of local nerve blockade that decreases pain immediately after operation and at 3months postoperatively. Furthermore, our method leads to shorter recovery room stay and fewer narcotics after operation.

Optimal Effect of Phenol Block in the Sciatic Nerve of Rats: Standardization of Minimized Dosage and Duration of Application.

The phenol nerve block has been widely used in clinical practice for spasticity reduction, but the correlation between the dosage of phenol and its effectiveness has seldom been discussed. The objective was to determine the optimal duration of phenol in contact with the nervous tissue and to investigate the dose-response relationship of 5% aqueous phenol solution by percutaneous nerve block in rats. Group I (n = 8) received sciatic nerve block by bathing the nerves in phenol solution, and group II (n = 40) by injecting phenol percutaneously. Group IIa to IId received different volumes (0.80, 0.16, 0.08 and 0.04 ml) and group IIe received normal saline. Compound muscle action potential (CMAP) was measured pre-injection and at 90 and 270 sec after injection and after surgical exposure of the nerves. The duration of CMAP reduced by 10%, 25%, 50%, 75% and 100% after phenol injection was also recorded. The mean latency for the evoked response to subside in direct phenol application (group I) and percutaneous nerve block (group IIa) were 73.5 ± 5.9 and 62.4 ± 7.6 sec, respectively. There was no statistical difference for the time periods in the blocking effect elicited by phenol solution between these two methods. Ninety sec was set as the optimal duration for phenol to produce complete conduction blockage. Higher volume of phenol produced more significant blocking effect at 90 and 270 sec after injection. Percutaneous injection with 0.16 ml of phenol solution had the same blocking effect as 0.8 ml. The continuous injection model for percutaneous phenol block indeed used significantly more phenol than actually needed. Clinically, the progressive injection model can be used to minimize injection volume.

A Case of Abducens Nerve Palsy after Percutaneous Nerve Block for Trigeminal Neuralgia

A Case of Abducens Nerve Palsy after Percutaneous Nerve Block for Trigeminal Neuralgia

Percutaneous sciatic nerve block with tramadol induces analgesia and motor blockade in two animal pain models

Local anesthetic efficacy of tramadol has been reported following intradermal application. Our aim was to investigate the effect of perineural tramadol as the sole analgesic in two pain models. Male Wistar rats (280-380 g; N = 5/group) were used in these experiments. A neurostimulation-guided sciatic nerve block was performed and 2% lidocaine or tramadol (1.25 and 5 mg) was perineurally injected in two different animal pain models. In the flinching behavior test, the number of flinches was evaluated and in the plantar incision model, mechanical and heat thresholds were measured. Motor effects of lidocaine and tramadol were quantified and a motor block score elaborated. Tramadol, 1.25 mg, completely blocked the first and reduced the second phase of the flinching behavior test. In the plantar incision model, tramadol (1.25 mg) increased both paw withdrawal latency in response to radiant heat (8.3 ± 1.1, 12.7 ± 1.8, 8.4 ± 0.8, and 11.1 ± 3.3 s) and mechanical threshold in response to von Frey filaments (459 ± 82.8, 447.5 ± 91.7, 320.1 ± 120, 126.43 ± 92.8 mN) at 5, 15, 30, and 60 min, respectively. Sham block or contralateral sciatic nerve block did not differ from perineural saline injection throughout the study in either model. The effect of tramadol was not antagonized by intraperitoneal naloxone. High dose tramadol (5 mg) blocked motor function as well as 2% lidocaine. In conclusion, tramadol blocks nociception and motor function in vivo similar to local anesthetics.

Percutaneous ilioinguinal-iliohypogastric nerve block or step-by-step local infiltration anesthesia for inguinal hernia repair: what cadaveric dissection says?

PurposeThe repair of groin hernias with local anesthesia has gained popularity. Two main methods have been described for local anesthesia. This study was aimed at comparing percutaneous truncular ilioinguinal-iliohypogastric block and step-by-step infiltration technique by using cadaver dissections.MethodsThe study was performed on an adult male cadaver by using blue dye injection. A percutaneous nerve block simulation was done on right side and the dye was given in between the internal oblique and transversus muscles. On the left side, a skin incision was deepened and the dye was injected under the external oblique aponeurosis. Following the injections, stained areas were investigated superficially and within the deeper tissues with dissection.ResultsThere was a complete superficial staining covering the iliohypogastric and ilioinguinal nerves in the inguinal floor at both sides. On the right side, intraabdominal observation showed a wide and intense peritoneal staining, while almost no staining was seen on the left side. Preperitoneal dissection displayed a massive staining including testicular vascular pedicule and vas deferens on the right side. The dye solution also infiltrated the area of the femoral nerve prominently. On the contrary, a very limited staining was seen on the left.ConclusionIt may not always be easy to keep the percutaneous block within optimum anatomical limits without causing adverse events. A step-by-step infiltration technique under direct surgical vision seems to be safer than percutaneous inguinal block for patients undergoing inguinal hernia repair.

Lumbar Sympathetic Chain Neuromodulation with Implanted Electrodes for Long-Term Pain Relief in Loin Pain Haematuria Syndrome

Introduction. Loin pain-hematuria syndrome (LPHS) is a rare clinical entity causing unilateral or bilateral intractable flank and loin pain with hematuria. The etiology is poorly understood, and the diagnosis is made by exclusion of urological and nephrological conditions. The management is mainly symptomatic aiming for pain relief with nonopioid and opioids analgesics, and interventions such as capsaicin infusion into the renal pelvis, percutaneous regional nerve blocks, and laparoscopic or open surgical procedures, none of them providing lasting pain relief. Methods. We describe four cases of LPHS in which long-term pain relief was achieved successfully by neuromodulation of lumbar sympathetic plexus with implanted electrodes. All patients underwent an initial successful trial of neuromodulation with Stimulong monoelectrode (Pajunk, GmbH, Geisingen, Germany) inserted percutaneously to lie adjacent to L3-L4 vertebral bodies followed by permanent implantation of the stimulation system using four contact electrodes (Medtronic Inc, Minneapolis, Minnesota, USA) in two patients with excellent long-term pain relief. Results. All our patients had significant reductions in visual analog scale scores and analgesic consumption for the duration of the monoelectrode trial and in one patient beyond six months. Of the two patients who had full implants, pain relief is excellent with minimal analgesic consumption and one has resumed employment. There were no complications. Discussion. LPHS is very difficult to treat with some experts maintaining it is mainly psychological. Conservative treatments are often unsatisfactory and radical measures not reliable. Peripheral stimulation of nerves and plexuses has been successful as shown from case reports. All our patients preferred low-frequency stimulation although its precise mode of action is uncertain. Conclusion. Our experience shows that lumbar sympathetic chain neuromodulation in intractable LPHS not amenable to conservative therapy is a reasonable alternative before radical interventions. More experience is needed in multiple centers before its recommendation for refractory LPHS.

Recurrent, Refractory, Metastatic And/Or Unresectable Pediatric Sarcomas: Treatment Options for Young People ‘Off the Roadmap’

Although sarcoma surgery is very important for cancer control, it is not always possible or practical to offer in some situations, including sarcoma recurrences, metastatic disease and/or unacceptable loss of function. We review some pragmatic approaches and examples of how to balance indications, risks and alternatives to control cancer in young people with sarcomas that are no longer using ‘front-line’ therapy. Radiotherapy combined with chemotherapy and outpatient ‘continuation’ chemotherapy regimens using drugs that cause less alopecia can improve function and quality of life. Some effective strategies to help cope when cure is not possible may include tumor ablation techniques performed in interventional radiology and percutaneous nerve blocks. Family centered care and effective problem solving of difficult issues can be greatly facilitated by consultation with a multidisciplinary team experienced in the management of very difficult cases. Treatment of young people with recurrent, relapsed and/or metastatic sarcoma still remains an art very much in the realm of compassion not protocol and persistent advocacy is required for the young person for whom cure may not be possible. A reduction of suffering and assistance in writing more chapters of a rich life narrative is the goal.