Thoracic Nerve Research Articles

Is RATS Superior to VATS in Thoracic Autonomic Nervous System Surgery?

Technological development in the field of robotics has meant that, in recent years, more and more thoracic surgery departments have adopted this type of approach at the expense of VATS, and today robotic surgery boasts numerous applications in malignant and benign thoracic pathology. Because autonomic nervous system surgery is a high-precision surgery, it is conceivable that the application of RATS could lead to improved outcomes and reduced side effects, but its feasibility has not yet been thoroughly studied. This review identified three main areas of application: (1) standard thoracic sympathectomy, (2) selective procedures, and (3) nerve reconstruction. Regarding standard sympathectomy and its usual areas of application, such as the management of hyperhidrosis and some cardiac and vascular conditions, the use of RATS is almost anecdotal. Instead, its impact can be decisive if we consider selective techniques such as ramicotomy, optimizing selective surgery of the communicating gray branches, which appears to reduce the incidence of compensatory sweating only when performed with the utmost care. Regarding sympathetic nerve reconstruction, there are several studies, although not conclusive, that point to it as a possible solution to reverse surgical nerve interruption. In conclusion, the characteristics of RATS might make it preferable to other techniques and, particularly, VATS, but to date, the data in the literature are too weak to draw any evidence.

POSITIVE SCRATCH COLLAPSE TEST IN ANTERIOR CUTANEOUS NERVE ENTRAPMENT SYNDROME (ACNES): EVIDENCE FOR A PERIPHERAL NEUROPATHY?

Abstract Background Chronic abdominal pain is occasionally caused by an abdominal wall entity such as Anterior Cutaneous Nerve Entrapment Syndrome (ACNES). This syndrome is thought to occur due to entrapped intercostal nerve branches (Th7-12) within the rectus abdominis muscles. This clinical diagnosis is based on subjective clues in patient history and physical examination. In contrast, in carpal tunnel syndrome an additional diagnostic test is used, which is referred to as the scratch collapse test (SCT). The SCT has shown positive results not only in other peripheral entrapment neuropathies involving the ulnar, peroneal, and long thoracic nerve, but also in three recently described ACNES patients. We investigated whether the SCT is of diagnostic use in patients suspected of having ACNES. Method A prospective, case-control study was performed among patients with ACNES (n = 20) and two control groups without ACNES (acute abdomen n = 20; healthy n = 20), all were consecutively included. ACNES was diagnosed based on previously published criteria. The SCT test was executed at the painful abdominal area in both patient groups and at a corresponding area in healthy controls. Predictive values, sensitivity, and specificity were calculated. Videos of tests were evaluated by blinded observers. Results SCT was judged positive in 19 of 20 ACNES patients, but not in any of the 40 controls. A 95% sensitivity (CI:75–99) and 100% specificity (CI: 83–100) were calculated. Conclusion This study provides strong evidence that ACNES should be considered as an entrapment neuropathy, while a positive SCT should be considered as a major diagnostic criterion.

Anatomical considerations for the subcutaneous implantable cardioverter-defibrillator (SICD) implantation: a cadaver-based analysis

Abstract Background Subcutaneous implantable cardioverter-defibrillators (SICDs) offer primary and secondary prevention of sudden death without transvenous leads in individuals not requiring pacing therapy. Intermuscular placement of the SICD generator between the latissimus dorsi (LDM) and serratus anterior (SAM) muscles is often recommended. This specific technique results in reduced defibrillation impedance and subsequently optimal defibrillation thresholds, reduced risk of pocket complications and infections, reduced device migration, and enhanced patient comfort and cosmetic outcomes. Despite the recommendation for an intermuscular implant technique utilizing a mid-axillary incision line, there is limited research describing this anatomical space to avoid complications. In this anatomic study, we examined this anatomical space. Our aim was to provide a better understanding of the interplay between the involved muscles and a proper location of an incision line. We also defined the location of the long thoracic nerve (LTN) relative to this space, which if transected, would lead to a winged scapula. Methods We examined 18 cadavers; 12 (66.7%) were female donors and 6 (33.3%) were males. We measured the distance from the anterior border of the LDM in relation to the cadaver back (A) and in relation to the anterior-posterior diameter of the chest (B). We performed these measurements at the 5th and 7th rib levels, and then averaged these measurements. We also measured the distance from the back to where the LTN enters SAM at the 4th, 5th, and 6th ribs. Results Analysis of the obtained data showed that the mean distance from the back to the anterior border of LDM at the 5th rib was 7.55 cm (5.65 – 10.85 cm) and at the 7th rib was 7.60 cm (5.35– 10.35 cm). Mean distance from the back to the anterior LDM border in both 5th and 7th ribs combined was 7.58 cm (5.50 – 1.06 cm). The mean anterior-posterior diameter of the chest wall at the fifth rib was 21.45 cm (18.55 – 24.75 cm). The mean A/B ratio (that is the ratio between the distance from the back to the anterior LDM border in comparison to the anterior-posterior chest diameter) was 0.4 with a standard deviation of +/- 0.1 (range 0.27-0.45). The LTN was running anterior to the LDM border at the 4th rib level, and posterior to the LDM border at the 5th and 6th ribs level. The LTN entered the SAM at the 4th rib level in 6.6%, at the 5th rib in 46.6% and at the 6th rib in 46.6% of cadavers. Discussion Intermuscular technique for S-ICD implantation is recommended as the preferred procedural approach. In our postmortem study, the anterior LDM border was variable but posterior to the mid-axillary line with a variable A/B ratio of 0.27 – 0.45. Our study also demonstrates the proximity of the long thoracic nerve (LTN) in comparison to the anterior LDM border. Caution should be taken when implanting S-ICD devices to avoid LTN injury.

An unusual relationship between the axillary artery and brachial plexus in a cross-breed dog cadaver: a proposal for revising the terminology for nerve loops

In the left axilla of a formalin-embalmed adult female cross-breed dog, an unusual course of the axillary artery in relation to the brachial plexus was noted. A part of the axillary artery after the origin of the subscapular artery coursed through the loop formed by the contributions of the caudal pectoral and lateral thoracic nerves and then between the median and ulnar nerves. Thus, the common trunk for the latter two nerves was missing. Instead, in the proximal brachium, they communicated with each other in both directions. A communicating branch between the cranial and caudal pectoral nerves forming a nerve loop, ansa pectoralis lacked the axillary artery and was instead traversed by the subscapular artery. This is a variation in the relationship between the axillary artery and brachial plexus in the domestic dog and has not been reported in the literature yet. The axillary artery entrapped by the contributions of the caudal and lateral thoracic nerves may be considered as a risk factor for the neuroarterial compressions with non-specific signs and should be taken into account both in surgery and imaging.

Abstract PO4-22-08: Ten-Year Oncologic Outcomes in T1-3N1 Breast Cancer After Targeted Axillary Sampling: A Retrospective Study

Abstract Background Targeted axillary sampling (TAS) is a new surgical concept for the assessment of axillary lymph node status in breast cancer that is hypothesized to be more effective at minimizing postoperative morbidities than axillary lymph node dissection (ALND), provided the metastatic axillary lymph node can be accurately detected without missing data; however, the oncologic outcomes over long-term follow-up have not been sufficiently investigated. This was a retrospective analysis to evaluate the 10-year oncologic outcomes in T1-3N1 breast cancer after TAS. Methods Clinically, we defined TAS as removal of a bunch of ALNs located around SLNs and targeted LNs, but without full exposure of the axillary vein, long thoracic nerve and thoracodorsal nerve. Between 2008 and 2013, 230 female patients with cT1-3N1 breast cancer underwent breast and axillary surgery (ALND, n = 171; TAS, n = 59) at our institute. After TAS was applied, additional axillary radiotherapy was performed. Various postoperative complications, including postoperative seroma, lymphedema, and 10-year oncological outcomes, were evaluated and compared between the ALND and TAS groups. Results Although overall survival during the 10-year follow-up period was better in the TAS group, there was no statistically significant difference in oncologic outcomes, including locoregional recurrence, distant metastasis, and overall survival (p = 0.395, 0.818, and 0.555, respectively). Furthermore, the incidence of lymphedema on the ipsilateral arm was significantly higher in the ALND group (p < 0.001). Conclusions The 10-year oncological outcomes of TAS were not inferior to those of conventional ALND in T1-3N1 breast cancers; however, the incidence of lymphedema was significantly higher in the ALND group. Citation Format: Byeongju Kang, Jeeyeon Lee, Yee Soo Chae, Ho Yong PARK, Jin Hyang Jung. Ten-Year Oncologic Outcomes in T1-3N1 Breast Cancer After Targeted Axillary Sampling: A Retrospective Study [abstract]. In: Proceedings of the 2023 San Antonio Breast Cancer Symposium; 2023 Dec 5-9; San Antonio, TX. Philadelphia (PA): AACR; Cancer Res 2024;84(9 Suppl):Abstract nr PO4-22-08.

An Unusual Life-threatening Presentation of a Common Complication in a Postoperative Case of Video-assisted Thoracoscopic Oesophagectomy

Oesophagectomy is associated with significant morbidity and mortality. It is associated with various complications such as anastomotic leaks, thoracic duct leaks, bleeding, aspiration pneumonia, arrhythmias and nerve palsies. A minimally invasive approach to surgery is preferred due to the reduced risk of associated complications. We report the case of a 65-year-old female who underwent oesophagectomy. Her postoperative phase was eventful as she developed a massive oronasal bleed, which was later found to be caused by an anastomotic leak causing erosion of the blood vessels. Our patient was resuscitated and managed with an emergent exploratory laparotomy. Herein, we report this case to highlight the importance of focussing on case-specific common complications manifesting in unusual presentations.

Long-term outcomes of pectoralis major transfer for scapular winging due to long thoracic nerve palsy: results after a median follow-up of 17 years

A pectoralis major (PM) transfer is a viable treatment option for patients with scapular winging due to long thoracic nerve (LTN) palsy not responding to nonsurgical management. However, the long-term outcomes remain unknown. Therefore, the purpose of this study was to evaluate the long-term outcome of shoulder function (ie, minimum follow-up of 10 years) and quality-of-life (QoL) of patients treated for scapular winging due to LTN palsy with a PM transfer. This observational cohort study included 15 patients (16 shoulders) who underwent PM transfer, using a tendoachilles allograft, between 1995 and 2012. Shoulder forward flexion and abduction were analyzed preoperatively, 1 year after surgery and at the final follow-up. SF-36 component scores (physical component summary (PCS) and mental component summary (MCS)) were used to evaluate the QoL. Shoulder forward flexion and abduction measured in degrees improved from 86 (SD 14.5) and 82 (SD 33.8) preoperatively to 140 (SD 27.3) and 138 (31.3) at 1 year postoperatively. After a median follow-up of 17 years, mean shoulder functions were slightly lower than at 1 year postoperatively, but still better than preoperative function, ie, forward flexion 121 (SD 41.9) and abduction 122 (SD 44.5). The mean PCS score at the final follow-up was 41.9 (SD 9.7), and the mean MCS score was 49.9 (SD 12.5). Better shoulder function at the final follow-up was significantly associated with higher QoL in terms of PCS scores (P=.023), but not MCS scores (P=.287). The results of the present study indicate that PM transfer augmented with an achilles tendon allograft for scapular winging due to LTN palsy leads to functional improvements that persist in long term. These functional improvements likely translate to better QoL based on their association.

On the Question of Differential Diagnosis of Skin Hyperpigmentations: The Clinical Case of Notalgia Paresthetica

Introduction. Developmental disorders acquire an extensive group of diseases, including congenital forms in inheritance variants, as well as secondary acquired forms due to skin or systemic manifestations.The purpose of this publication is to demonstrate the features of the differential diagnosis of skin hyperpigmentation to identify the clinical manifestation of notalgia paresthetica.Materials and methods. A review of foreign and domestic literary sources was carried out using the search engines eLibrary.Ru, Scopus, PubMed. On the basis of the patient’s voluntary informed consent, an analysis of medical documentation was carried out, taking into account clinical and anamnestic data and the results of laboratory and instrumental examination. Results. The article presents a review of the literature, as well as a clinical case of notalgia paresthetica in a patient with degenerative-dystrophic changes in the thoracic spine.Discussion. Notalgia paresthetica belongs to a large group of cutaneous dysesthesias and is a sensory neuropathy characterized by localized unilateral itching and hyperpigmentation of the skin of the back in the zone of innervation of the cutaneous branches of the thoracic spinal nerves, affecting more often adult and elderly women. The nonspecificity of skin manifestations of notalgia paresthetica and the low awareness of doctors about this disease can lead to diagnostic and tactical errors. Skin itching of varying intensity is the main symptom of the disease, leading to an accentuation of its disease and a decrease in the quality of life of patients.Conclusion. Given the interdisciplinary nature of the pathology, the article may be of interest to neurologists, neurosurgeons, dermatovenereologists, general practitioners, general practitioners, oncologists, and endocrinologists.

Rare nerve compression neuropathies

In regard to the complex anatomical relationship of peripheral nerves and muscles, tendons, fasciae as well as their long course within those anatomical structures and additional close contact to bony structures, they are prone to suffer from local compression syndromes. Hence creating a vast majority of entrapment syndromes - well described in literature for almost every single nerve. The purpose of this article is to give an overview of symptoms, signs, diagnostic studies and treatment options, addressing especially the less known syndromes. Compression syndromes of the upper arm and shoulder region include the suprascapular nerve syndrome the compression of the axillary nerve within the spatium quadrilaterale and the compression of the long thoracic nerve at the chest wall. The upper extremity offers a variety of infrequent entrapment syndromes, as the pronator teres syndrome and anterior interosseus syndrome, both resulting from pressure to the median nerve in the forearm. Compression neuropathy in the course of the radial nerve in the distal upper extremity is also known as supinator syndrome. Guyon's canal syndrome is the ulnar side equivalent to the well-known carpal tunnel syndrome. In the case of a Cheiralgia paresthetica, a compression of a sensory branch of the superficial radial nerve can be seen. In the lower extremities, a variety of nerves especially in the groin and thigh area can be compressed as they pass through the narrow spaces between the abdominal muscles or underneath the inguinal ligament. Compression of the lateral femoral cutaneous nerve is the most common syndrome. Compression syndromes of the femoral and obturator nerves are most often iatrogenic. Pain around the knee, especially the lateral part and following orthopedic procedures of the knee, can arise from a compression or a lesion of a small infrapatellar branch of the saphenous nerve. Another probably underdiagnosed syndrome is piriformis syndrome, resulting from an entrapment of the sciatic nerve as it passes through certain muscular structures. In the distal lower extremity, the peroneal and tibial nerves can be compressed at multple sites, clinically known as peroneal nerve paralysis resulting from nerve compression around the fibular head, the anterior and posterior tarsal tunnel syndrome, and Morton's metatarsalgia.

Assessing the Impact of General Anesthesia and Bronchial Intubation in Conjunction with Thoracic Paravertebral Nerve Block on Cellular Immunity and Surgical Management in Tuberculous Pyothorax Patients

Objective: This study aims to investigate the impact of combining general anesthesia with bronchial intubation and thoracic paravertebral nerve block during surgery for patients with tuberculous pyothorax. Methods: Eighty patients diagnosed with tuberculous pyothorax, admitted to the hospital between January 2023 and September 2023, were randomly selected for this study. The patients were divided into control and study groups using a numerical table method. The control group underwent general anesthesia with bronchial intubation, while the study group received general anesthesia with bronchial intubation in conjunction with thoracic paravertebral nerve block. Subsequently, the patients were monitored to assess mean arterial pressure, heart rate variations, and adverse reactions to anesthesia. Results: The study group exhibited significantly lower mean arterial pressure and heart rate levels during the post-surgical incision, immediate end of surgery, and immediate extubation periods compared to the control group (P < 0.05). Furthermore, the Ricker and Ramsay scores in the study group were significantly lower than those in the control group (P < 0.05). Conclusion: The combined use of general anesthesia via bronchial intubation and thoracic paravertebral nerve block has been found to stabilize mean arterial pressure and heart rate while providing effective sedation for surgical treatment in patients with tuberculous septic thorax.

Efficacy of postoperative analgesia with intravenous paracetamol and mannitol injection, combined with thoracic paravertebral nerve block in post video-assisted thoracoscopic surgery pain: a prospective, randomized, double-blind controlled trial

BackgroundAlthough video-assisted thoracoscopic surgery (VATS) has advantages of reduced injury and faster healing, patients still endure moderate and severe postoperative pain. Paracetamol and mannitol injection, the first acetaminophen injection in China, has the advantages of convenient administration, rapid onset of action, and no first-pass effect. This aim of this study was to investigate the efficacy of postoperative analgesia with paracetamol and mannitol injection, combined with thoracic paravertebral nerve block (TPVB) in post VATS pain.MethodsThis study was a single-center, prospective, randomized, double-blind controlled clinical trial. Patients scheduled for VATS were randomly divided into three groups, general anesthesia group (Group C), TPVB group (Group T) and TPVB + paracetamol and mannitol injection group (Group TP). In this study, the primary outcome was determined as visual analog scale (VAS) scores at rest and coughing, the secondary observation outcomes were the first time to use analgesic pump, the total consumption of oxycodone in the analgesic pump, number of effective and total analgesic pump compressions at first 48 h postoperatively, the perioperative consumption of sufentanil, time to extubation, hospital length of stay, urine volume, and the incidence of adverse events.ResultsIn a state of rest and cough, patients in the Group TP showed significantly lower VAS pain scores at 1, 12, 24, and 48 postoperative-hour compared with Group C and Group T. Intraoperative sufentanil and postoperative oxycodone consumption, the first time to press analgesic pump, the times of effective and total compressions of patient- controlled analgesia (PCA) were lower than those of the Group C and Group T. Interestingly, urine output was higher in Group TP. There were no differences between the three groups in terms of extubation time, length of hospital stay and adverse effects, indicating that intravenous paracetamol and mannitol injection is an effective and safe perioperative analgesia method.ConclusionsParacetamol and mannitol injection, combined with TPVB may provide important beneficial effects on acute pain control and reduce the consumption of opioid in patients undergoing VATS.Trial registrationThe trial was registered on Jun 19, 2023 in the Chinese Clinical Trial Registry (https://www.chictr.org.cn/showproj.html?proj=199315), registration number ChiCTR2300072623 (19/06/2023).

Treatment of Brachial Plexus Injuries following Gunshot Injuries: A Systematic Review.

Brachial plexus injuries (BPI) from gunshot injuries are uncommon but usually severe and can cause chronic pain, loss of function, and permanent nerve damage. Multiple surgical techniques including neurolysis, end-to-end suture repair, and graft repair have been described for the treatment of these injuries. However, surgical indication, timing, and technique for these injuries remain controversial. This systematic review aims to investigate the treatment modalities for patients with BPI due to gunshot-related injuries. The Preferred Reporting Items for Systematic Reviews and Meta-Analysis (PRISMA) methodology was employed for this review. PubMed, Cochrane Reviews, Embase, and CINAHL databases were included. The following keywords constituted our search criteria: gun-shot-wounds, brachial plexus, traum∗, and management. A total of 90 studies were imported for screening, from which 9 papers met our final inclusion/exclusion criteria. The most common studies utilized in this review were retrospective chart reviews followed by case series. In total, there were 628 patients that suffered from gunshot wounds to the brachial plexus. Most patients underwent some form of delayed nerve repair consisting of neurolysis, end-to-end epineural repair, or graft repair with a sural or antebrachial cutaneous nerve graft. Several patients suffered from complications, with neuroma being the most common long-term complication that required reoperation. The optimal timing for surgeries involving BPIs should be determined after examining the level of nerve damage, associated injuries, operative risks, and electrophysiological workup for indications of spontaneous regeneration. Early surgical interventions were indicated for patients presenting with associated vascular or thoracic injuries, compressive masses, and nerve transection by sharp instruments in most selected papers.

Meta-analysis of the effects of ultrasound-guided rhomboid-intercostal-low anterior serratus plane block and thoracic paravertebral nerve block for postoperative analgesia in adults undergoing thoracoscopic surgery

Meta-analysis of the effects of ultrasound-guided rhomboid-intercostal-low anterior serratus plane block and thoracic paravertebral nerve block for postoperative analgesia in adults undergoing thoracoscopic surgery

Ultrasound appearance and targeted therapy of symptomatic neural lesions in the breast and chest wall after breast cancer surgery.

To evaluate the feasibility of ultrasound (US) in identification of nerve lesions after breast cancer surgery in patients with neuropathic pain and assess the effect of a targeted US-guided therapy. Patients with neuropathic pain after breast cancer surgery underwent US examination. Nerve lesions identified by US were treated by a US-guided application of a mixture of local anesthetics and corticoids. The patients reported pain relief on a 100-point scale (0% = no effect, 100% = complete relief) and its duration in the next 18 months. We performed 17 interventions in 11 women. A neuroma was observed in 2 patients, edema of the nerve in 5 patients, and scarring across the nerve in 4 patients. The affected nerves were the intercostobrachial nerve (5 patients), the long thoracic nerve (4), cutaneous branch of the pectoral nerve (1), and both the intercostobrachial and the long thoracic nerve (1). After 15 (88%) interventions, the patients reported relief (55±32%) with a median duration of 3 months (0.5-18 months). In patients after breast cancer surgery, ultrasound can reliably identify small painful neural lesions which can be efficiently treated by ultrasound-guided intervention.

Reactivation of varicella zoster virus following trigeminal schwannoma resection.

Varicella zoster is found exclusively in humans. Infected people with this virus result in chickenpox followed by dormant virus within neural ganglia. This dormant virus, once activated, may affect any ganglia or nerves of the body but most commonly involves the thoracic, cervical and trigeminal nerves in decreasing order of frequency. We review three such cases in which manipulation of the trigeminal ganglion resulted in reactivation of varicella at homologous operative sites. Each patient underwent surgeries in which the trigeminal ganglion was manipulated for the resection of trigeminal schwannoma under a microscope through various approaches. All three patients developed reactivation of varicella at homologous operative sites. A thorough history of chickenpox infection should be taken in patients who are undergoing surgeries for trigeminal pathology. Early diagnosis should be made once any vesicular lesions are seen with prompt treatment. Reassurance and counselling are necessary in these patients. If possible, prophylaxis may be started in all such patients. Further studies are warranted to determine the exact cause of reactivation.

Rhomboid intercostal sub serratus plane block – Same bird with different horizons

Sir,We did a case series in five patients undergoing modified radical mastectomy who were given RISS for post-operative analgesia. We noticed that the intraoperative fentanyl consumption as well as the post-operative analgesic consumption was significantly less. The overall quality of life and satisfaction score for routine daily activities like wearing clothes was better in our patients. The importance and efficacy of these blocks are because of the continuity of the interfacial planes across varied anatomical tissues. These planes have various cutaneous as well as sympathetic branches and hence drug given spreads to cover a large dermatomal area. RISS has been proposed to cover lateral cutaneous branches of T2 to T11 that extend medially to cover dorsal rami deep to the errector spinae muscle plane (ESP). The site of injectate is at T5-T6. The dermatomal coverage is 4 cm lateral to the midline anteriorly, posteriorly 4 cm medial to the posterior axillary line, cranially up to serrated posterior superior caudally up to serratus posterior inferior. The advantages of RISS block are that the injection is far from the surgical site and hence the drug does not interfere with the surgical field or cautery if given preoperatively. After induction technically, it is more feasible than serratus plane block or pectoral blocks. Logistically prior catheterization is possible that does not interfere with the sterility of the surgical field. Despite the above advantages, the axillary coverage is inconsistent as it does not cover the intercostobrachial nerve (LCB of second ICN T2). The midline, thoracodorsal nerve, and long thoracic nerve are not covered. Complete analgesia is not provided for latissimus dorsi flap, segmental resection surgeries, lymph node dissections, or radical mastectomies. Dr. Tulgar, first-ever reported of the use of RIB in a patient of MRM and highlighted the superiority of peri-peri-paravertebral blocks apart from previously used ESP and paravertebral blocks for a similar condition. Altiparimak conducted an RCT on 30 MRM patients with axillary lymph node dissection. The patients had enhanced recovery and quality of life scores (QoR-40), especially in terms of pain and emotional status. RISS has proved its non-inferiority as compared to ESP, paravertebral, PEC, and SAP which are closer to neuroaxis, at non-compressible sites and difficult to execute in obese patients. Thus RISS is excellent as a part of MMA for post-operative pain management in MRM patients, who remain comfortable for up to 14 h and have an NRS score <3 was seen in all of our five patients. The dynamic nature of pain was apparent at 14 h in three of the patients who had extensive axillary lymph node dissection. Is the journey of regional anesthesia just the replacement of “pops and clicks” with see it and block it? The renaissance in the era of blocks is visualizing an invention of a new block almost every month. We depend on the facial plane anatomy, its structure, and its relation to the surrounding organs and tissues to precisely disseminate the local anesthetic to its desired location. In this blind sheep race, enthusiasm should not blur our understanding of the basics. We should remember Triple A, improve health, enhance patient outcomes, and decrease the costs. We open the doors for larger studies with more patients, comparing different blocks with RIB/RISS blocks before generalizing the results. CONCLUSIONRhomboid intercostal subserratus plane block is an excellent option for intra and post-operative pain management as a part of multimodal analgesia in MRM patients.

THORACIC LONGUS NERVE LESION IN A PATIENT WITH ANKYLOSING SPONDYLITIS

The paper presents a 33 - year - old patient who has been suffering from ankylosing spondylitis since the age of 28. Pain in his right shoulder and weakness in his right arm developed after more hours of walking with a backpack. The performed procedure diagnosed a lesion of the long thoracic nerve without of sensory damage. Peripheral nerve injuries long thoracic nerve lead to weakness of the muscles -serratus anterior muscle and result in a protrusion of the medial side of the scapula (scapula alata). It is difficult to raise the arm in the shoulder joint above the horizontal line, that is to raise the shoulder from the chest when the arm is extended and pressed against a fixed object in front of the patient. Due to its long, relatively superficial course, long thoracic nerve is susceptible to injury, either through direct trauma or stretching. The long thoracic nerve, also called Charles Bell’s external respiratory nerve, is a rare isolated nerve damage. The nerve is often injured from carrying a load on his shoulder, with supraclavicular and axillary injuries, blows in the neck area. Injury has been reported in almost all sports, usually occurring from a blow to the ribs with an outstretched arm. Long thoracic nerve can be damaged during breast cancer surgery, especially radical mastectomy that involve the removal of axillary lymph nodes. It is a common lesion in spinal surgeries. Key words: Lesion, long thoracic nerve, ankylosing spondylitis

Effects of different anesthesia methods on perioperative immune function and long-term regression of patients undergoing thoracoscopic radical esophagectomy for esophageal cancer

ObjectiveThis study investigated the effects of different anesthetic methods on perioperative immune function and long-term regression of patients undergoing thoracoscopic radical surgery for esophageal cancer. MethodsData from 147 patients undergoing thoracoscopic radical surgery for esophageal cancer in our hospital from January 2017 to June 2019 were selected for retrospective analysis. Patients were divided into control (intravenous anesthesia combined with an epidural block, n = 83) and observation (intravenous anesthesia combined with a thoracic paravertebral nerve block, n = 64) groups. The use of relevant drugs during the surgery, indexes of the peripheral blood T-lymphocyte subpopulation at different time points (before induction of anesthesia, at the completion of surgery, 24 h postoperatively, and 48 h postoperatively), and 3-year postoperative survival were compared between the two groups. ResultsData on propofol and remifentanil use during surgery were not significantly different (P > 0.05) between the two groups. The proportion of vasoactive drug use was lower in the observation group than in the control group (P < 0.05). Differences in data for CD3+, CD4+, and CD4+/CD8+ cells between time points were significant (F = 13.256, 20.307, 18.035, P < 0.05), while those between the two groups were not (F = 1.005, 1.135, 1.204, P > 0.05). There was no interaction between data processing factors and time between the control and observation groups in CD3+, CD4+, and CD4+/CD8+ cells (F = 0.358, 0.778, 1.107, P > 0.05). The median overall survival time was 21.988 (95 % confidence interval: 18.436–25.541) and 26.978 (95 % confidence interval: 20.124–33.833) months in the control and observation groups, respectively, with a significant difference between the two groups (Log-rank χ2 = 3.925, P < 0.05). ConclusionsBoth anesthetic methods achieve satisfactory anesthetic results and reduce postoperative stress and immunosuppression. However intravenous anesthesia combined with an epidural block can increase the incidence of intraoperative hypotension in the patients, thoracic paravertebral nerve block combined with general anesthesia is more favorable for maintaining intraoperative blood pressure and heart rate stability, as well as for postoperative survival.

Assessment of an Ultrasound-Guided Rectus Sheath Block in Foals: A Cadaveric Study

In neonatal equines, pathologies involving umbilical structures are an important cause of morbidity, and surgical removal of urachal remnants is a common procedure in clinical practice. Surgery involving the ventral abdominal wall can cause substantial pain, leading to complications and prolonged recovery. The objectives of this study were to describe a two-point bilateral ultrasound-guided rectus sheath block at the level of the umbilicus and to evaluate the extent of dye distribution in foal cadavers. Ten foal cadavers were included in the study, in which a bilateral two-point ultrasound-guided rectus sheath block was performed—one injection 5 cm cranially and a second one 5 cm caudally to the umbilicus. The injectate consisted of a mixture of iodinated contrast medium and blue dye at a volume of 0.25 mL kg−1 per injection point (total 1 mL kg−1). After the injection, computer tomography and subsequent dissection of the ventral abdominal wall were performed. The extension of the contrast medium, the number of stained nerves, and contamination of the abdominal cavity were evaluated. The cranio-caudal extension of the contrast ranged from 0.8 to 1.4 cm per milliliter of injectate. The most commonly stained ventral branches of spinal nerves were thoracic (Th) nerves 16, 17, and 18 (95%, 85%, and 80% of the nerves, respectively). Abdominal contamination was found in four animals. The results suggest that the block could provide periumbilical analgesia. Further studies with different volumes of injectate and living animals are warranted.

Impact of Simulation Training on the Management of Shoulder Dystocia and Incidence of Permanent Brachial Plexus Birth Injury: An Observational Study

(BJOG. 2023;130:70–77) During complicated deliveries, brachial plexus birth injury (BPBI) is likely to occur. BPBI is caused by traction to the cervical and thoracic nerve roots. Shoulder dystocia (SD) is the greatest risk factor for permanent BPBI. Simulation-based training has been suggested to prepare healthcare professionals for deliveries involving BPBI and SD, but the outcomes and results of this training are inconsistent and uncommon.