Thoracic Nerve Research Articles

Safety and feasibility of ultrasound-guided serratus anterior plane block and intercostal nerve block for management of post-sternotomy pain in pediatric cardiac patients: A prospective, randomized trial

BackgroundPostoperative analgesia in the cardiothoracic ICU has traditionally relied on intravenous opioids. Thoracic nerve blocks are attractive alternatives for analgesia that reduce the requirement for opioids, but their safety and feasibility remain unclear. MethodsSixty children were allocated randomly to three groups: group C received intravenous opioids alone, while group SAPB (deep serratus anterior plane block) and group ICNB (intercostal nerve block) received opioids combined with ultrasound-guided regional nerve blocks (0.2% ropivacaine 2.5 mg.kg−1) after patients were transferred to the ICU. The primary outcome was opioid requirement in the first 24 h after surgery. Other outcomes included the postoperative FLACC scale value, tracheal extubation time, and plasma ropivacaine concentrations after the block. ResultsThe mean [sd] cumulative dose of opioids administered postoperatively within 24 h in the SAPB (168.6 [76.9] μg.kg−1) and ICNB groups (170.0 [86.8] μg.kg−1) were significantly lower by nearly 53% than those in group C (359.3 [125.3] μg.kg−1, p = 0.000). The tracheal extubation time was shorter in the regional block groups than that in the control group, but the difference was not statistically significant (p = 0.177). The FLACC scale values at 0, 1, 3, 6, 12, and 24 h post-extubation were similar in the three groups. The mean peak plasma ropivacaine concentrations in the SAP and ICNB groups were 2.1 [0.8] and 1.8 [0.7] mg.L−1, respectively, 10 min post-block and then slowly decreased. No noticeable complications associated with regional anesthesia were observed. ConclusionsUltrasound-guided SAPB and ICNB provided safe and satisfactory early postoperative analgesia while reducing opioid consumption following sternotomy in pediatric patients. Clinical trial registrationChinese Clinical Trial Registry ChiChiCTR2100046754.

Unilateral thoracic spinal nerve resection creates early onset thoracic scoliosis in an immature porcine model.

To test whether multiple-level unilateral thoracic spinal nerves (TSN) resection can induce the initial thoracic cage deformity to cause early onset thoracic scoliosis in an immature porcine model; and 2) to create an early onset thoracic scoliosis in a large animal model that can be used to evaluate growth-friendly surgical techniques and instruments in growing spine researches. Seventeen one-month-old pigs were assigned to 3 groups. In group 1 (n = 6), right TSN were resected from T7 to T14 with the contralateral (left) paraspinal muscle exposing and stripping. In group 2 (n = 5), the animals were treated in the same way except the contralateral (left) side was intact. In group 3 (n = 6), bilateral TSN were resected from T7 to T14. All animals were followed up for 17-weeks. Radiographs were measured and analyzed the correlation between the Cobb angle and thoracic cage deformity. A histological examination of the intercostal muscle (ICM) was performed. In the groups 1 and 2, an average 62 ± 12° and 42 ± 15° right thoracic scoliosis with apical hypokyphosis of a mean -5.2 ± 16° and -1.8 ± 9° were created, respectively, during 17-weeks follow up. All curves were located at the operated levels with the convexity toward the TSN resection side. Statistical analysis demonstrated that the thoracic deformities were strongly correlated with the Cobb angle. In group 3, no scoliosis was created in any animal, but an average thoracic lordosis of -32.3 ± 20.3° was seen. The histological examination showed the ICM denervation on the TSN resection side. Unilateral TSN resection induced the initial thoracic deformity toward the TSN resection side resulting in thoracic hypokyphotic scoliosis in an immature pig model. This early onset thoracic scoliosis model could be used to evaluate the growth-friendly surgical techniques and instruments in future growing spine researches.

Serratus anterior plane block versus thoracic epidural block in patients undergoing thoracotomy: a randomized double-blind trial

Background & Objective: Standard pain management technique after thoracic surgery is thoracic epidural analgesia, parentral analgesics and nerve blocks. Thoracic epidural analgesia (TEA) has many known complications, including respiratory depression and urinary retention. Serratus anterior plane block (SAPB) is a simple procedure, which provides postoperative pain relief by blocking the lateral cutaneous branches of T2–T9 spinal neurons. We compared the analgesic efficacy of both of these techniques in thoracotomy patients in this randomized trial.
 Methodology: The study involved 74 cancer patients scheduled for thoracotomy. The patients were randomly divided into two groups. The patients in Group SAPB underwent ultrasound-guided serratus anterior plan block (SAPB) with catheter insertion. The second group (Group TEA) underwent TEA with preoperative indwelling catheter insertion. In both groups blocks were activated before induction of routine general anesthesia (GA) by a bupivacaine bolus dose, then continued as bupivacaine infusion in ICU for postoperative analgesia. Hemodynamic monitoring was started. Intraoperative fentanyl consumption, postoperative morphine consumption, and time to first request for analgesic were noted including MAP in the two groups.
 Results: Both groups were statistically comparable regarding intraoperative fentanyl consumption, postoperative morphine consumption, and time to first request for analgesia in the two groups. Hypotensive episodes were significantly more frequent (P < 0.001) in the TEA group (n = 17; 45.9%) compared to the Group SAPB (n = 2; 5.4%). Ramsey sedation scores (RSS) were comparable in the two groups immediately postoperatively and after 2 h. After 4 h after recovery all patients in both groups had an RSS of 2.
 Conclusion: Ultrasound-guided serratus anterior plane block is associated with reduced intraoperative and postoperative fentanyl consumption, but the Ramsey sedation scores were equivalent in the two groups after recovery and upto 4h.
 Abbreviations: GA: General Anesthesia; PTPS: Post-Thoracotomy Pain Syndrome: RSS: Ramsey Sedation Score; SAPB: Serratus Anterior Plane Block; TEA: Thoracic Epidural Analgesia; VATS: Video-Assisted Thoracoscopic Surgery
 Key words: Pain, Postoperative; Serrataus plane block; Thoracotomy; Ultrasound; Thoracic epidural
 Citation: Gamal RM, Bossily SS, Ali AR, Samy SF, Seif NE, Ahmed HI. Serratus anterior plane block versus thoracic epidural block in patients undergoing thoracotomy: a randomized double-blind trial. Anaesth. pain intensive care 2023;27(3):389−395.
 DOI: 10.35975/apic.v27i3.2243
 Received: March 06, 2023; Reviewed: March 31, 2023; Accepted: April 01, 2023

A Case Study on a Collegiate Baseball Player with Long Thoracic Nerve Palsy

A Case Study on a Collegiate Baseball Player with Long Thoracic Nerve Palsy

Neurolysis of the Long Thoracic Nerve for Scapular Winging due to Isolated Serratus Anterior Palsy: Early and Midterm Results in 29 Patients

ObjectiveThis study aimed to report our surgical outcomes of thoracic long thoracic nerve (LTN) decompression in patients with isolated LTN palsy, using a clinical scoring system designed to facilitate the grading of scapular winging severity. MethodsThis was a retrospective review of patients who had undergone decompression and neurolysis of the LTN for scapular winging. Each patient underwent needle electromyography of the serratus anterior for confirmation of diagnosis and were refractory to a minimum of 6 months of nonoperative management. Preoperatively and at final follow-up, shoulder range of motion and the Wrightington Winging Score (WWS) was used to objectively grade the dynamic and static components of winging. ResultsBetween 2014 and 2020, 29 patients who underwent thoracic neurolysis for scapular winging were analyzed. These were 16 males and 13 females with a mean age of 37 years. The injury mechanism was due to trauma in 19 cases and neuralgic amyotrophy in 10. The median duration between winging onset and surgery was 30 months. There were significant improvements in mean active shoulder abduction and forward flexion. Winging was noticeably improved in 22 patients. At presentation, the median WWS was 3, which improved to 1 at final follow-up. ConclusionIn patients with isolated LTN palsy causing persistent scapular winging which is not responsive to conservative treatment, neurolysis of the thoracic portion of the LTN can be considered. Level of EvidenceIV.

Comparison of CT-guided thoracic sympathetic nerve block and radiofrequency in the treatment of primary palmar hyperhidrosis.

Primary palmar hyperhidrosis (PPH) is a condition marked by an overactive secretion of the hand's exocrine glands and is frequently hereditary. The profuse sweating associated with this condition can significantly impair the patient's daily activities and quality of life. The objective of this study was to compared the benefits and drawbacks of thoracic sympathetic block and thoracic sympathetic radiofrequency in the treatment of PPH. A retrospective analysis was conducted on 69 patients. They were divided into groups A and B according to their treatment. Group A (34 cases) received CT-guided percutaneous thoracic sympathetic nerve chain anhydrous alcohol chemical damage block, and group B (35 cases) received CT-guided percutaneous thoracic sympathetic nerve chain radiofrequency thermocoagulation. Palmar sweating disappeared immediately after the operation. The recurrence rates at 1, 3, 6, 12, 24, and 36 months were 5.88% vs. 2.86% (P > 0.05), 20.59% vs. 5.71% (P > 0.05), 32.35% vs. 11.43% (P < 0.05),32.35% vs. 11.43% (P < 0.05), 25% vs. 14.71% (P < 0.05), and 68.75% vs. 20.59% (P < 0.05), respectively. The incidence of intercostal neuralgia and compensatory hyperhidrosis was higher in group A compared with of group B (52.94% vs. 22.86%, P < 0.05; 55.88% vs. 22.86%, P < 0.05). Both methods were found to be effective in treating PPH, but thoracic sympathetic radiofrequency had a longer-term effect, a lower recurrence rate, and a lower incidence of intercostal neuralgia and compensatory hyperhidrosis than a thoracic sympathetic block.

Scapular Winging in a Young Tennis Player: A Case Report

BACKGROUND: Facioscapulohumeral muscular dystrophy (FSHD) is often characterized by weakness of the scapular stabilizing muscles. FSHD is a genetic disorder in which skeletal muscles of the face (facio), the shoulder blades (scapulo), arms (humeral), and other muscles progressively weaken over time. 5 CASE PRESENTATION: A 13-year-old tennis player developed progressive right shoulder pain and limited range of motion. He did not have a precedent injury and his symptoms were exacerbated by tennis. His exam was notable for medial scapular winging. An electromyogram was read as a long thoracic nerve palsy, presumed to be a tennis-related traction injury. He was treated with aggressive therapy, taping, and bracing to improve scapulothoracic and glenohumeral biomechanics for optimal upper extremity strength and range of motion. OUTCOME AND FOLLOW-UP: His pain and motion improved, but he was unable to return to his prior level of tennis competition. Eighteen months after the initial diagnosis, the patient presented with similar symptoms and findings on the contralateral side, raising concern for a neuromuscular etiology. DISCUSSION: A repeat electromyogram and genetic tests were consistent with FSHD, rather than a sport-related peripheral nerve injury. JOSPT Cases 2023;3(2):96–99. Epub: 13 March 2023. doi:10.2519/josptcases.2023.10887

A Combination of Three Nerve Entrapment Syndromes, Which was Difficult to Differentiate from a Vertebral Compression Fracture.

This report describes the educational case of a patient who developed three different cutaneous nerve entrapment syndromes at the same level of the thoracic nerve, which was difficult to differentiate from a vertebral compression fracture. A 74-year-old woman presented with right lower abdominal pain, followed by back and flank pain. During later assessment, anterior, posterior and lateral cutaneous nerve entrapment syndromes at the Th11 level were diagnosed. A combination of three different cutaneous nerve entrapment syndromes can occur in the same patient. A combination of three cutaneous nerve entrapment syndromes can occur in the same patient.Cutaneous nerve entrapment syndromes are difficult to differentiate from vertebral compression fractures.

Bing–Neel Syndrome and Coexisting Pituitary Macroadenoma in a Patient with Waldenström Macroglobulinemia Revealed by 18F-FDG and 68Ga-Pentixafor PET/CT

A 63-year-old man presenting with peripheral neuropathies was diagnosed of Waldenström's macroglobulinemia, and Bing-Neel syndrome was subsequently confirmed via cerebrospinal fluid examinations. Besides involvement in bone marrow, lymph nodes, as well as the thoracic and sacral nerve root, 68Ga-Pentixafor PET/CT detected active tracer uptake in bilateral choroid plexus, which was negative in 18F-FDG PET/CT, possibly suggesting the involvement of Bing-Neel syndrome. The coexisting pituitary macroadenoma was FDG-avid but negative in 68Ga-Pentixafor PET/CT. After six cycles of chemotherapy, the follow-up PET/CT showed complete remission of the previous disease, including the high uptake of 68Ga-Pentixafor in choroid plexus. However, the hypermetabolic pituitary macroadenoma remained unchanged.

Videothoracoscopic splanchnicectomy as a method of treatment of the chronic pain syndromes in pancreatic cancer and chronic pancreatitis

Background: Chronic pain is a serious problem occurring in patients suffering from pancreatic cancer or chronic pancreatitis. It often contributes to anorexia and significantly deteriorates the quality of life, including the possibility of shortening the survival of such patients. Thoracoscopic splanchnicectomy is a surgical procedure consisted of the excision of the major thoracic visceral nerve or its branches, which attend the transmission of pain stimuli from the abdominal viscera. &#x0D; Aim of the study: The study aim is to indicate benefits of videothoracoscopic splanchnicectomy as a procedure performed in chronic pain management in patients suffering from pancreatic cancer and chronic pancreatitis. &#x0D; Material and methods: The literature available in the databases such as PubMed, Google Scholar and polish scientific journals was reviewed, using the following keywords: videothoracoscopic splanchnicectomy, pancreatic cancer, chronic pancreatitis.&#x0D; Results and conclusions: Videothoracoscopic splanchnicectomy is a minimally invasive yet highly effective surgical procedure, which allows to avoid traumatizing procedures such as thoracotomy or laparotomy in patients suffering from a severe chronic pain associated with pancreatic cancer, chronic pancreatitis and other conditions. Moreover it contributes to a statistically significant decrease in pain intensity and considerably improves the quality of patients’ lives.

Clinical effect of acupuncture along fascia, meridians, and nerves combined with ultrasound-guided paravertebral nerve block in the treatment of postherpetic neuralgia: a randomized parallel-controlled study.

To observe the clinical efficacy of acupuncture along fascia, meridians, and nerves combined with ultrasound-guided nerve blockage in the treatment of postherpetic neuralgia. A total of 61 outpatients with post-chest and back herpes zoster neuralgia were recruited in the Department of Pain at the Xiyuan Hospital, China Academy of Chinese Medical Sciences from May 2019 to June 2021. They were randomly divided into two groups. Thirty-one patients in the control group were treated with ultrasound-guided thoracic paravertebral nerve block (PVB) alone, one patient declined to continue during treatment ( 30), and thirty patients in the observation group received the acupuncture along the fascia, meridians, and nerves combined with ultrasound-guided PVB treatment ( 30). Both control and observation group received treatment weekly for 4 weeks. The medical history data such as age, sex, presence or absence of comorbidities and disease course were analyzed. The visual analog scale (VAS) score was used to assess the pain degree of two groups at T0 (before treatment), T1 (1-time treatment ended), T2 (2 times treatment ended), T3 (3 times treatment ended), and T4 (4 times treatment ended). The sleep state was examined by Pittsburgh Sleep Quality Index (PSQI) before and after the study. There was no significant difference in general conditions between the control group and the observation group (> 0.05). The VAS score in both control and observation group was decreased in a time-dependent manner after 1-4 weeks of treatment. There were no significant differences in VAS scores between the two groups after 1 or 2 weeks of treatment ( > 0.05). After 3 and 4 weeks of treatment, the VAS score was significantly decreased in the observation group compared with that in the control group ( < 0.001). In addition, the reduction in VAS score (after treatment-before treatment) between the two groups was statistically significant [D value: -1.53, 95% (-2.32, 0.74), < 0.001]. Furthermore, the sleep state of patients in both groups markedly improved and much obvious in the observation group than that in the control group ( < 0.05). These results suggest that a combination of acupuncture along fascia, meridians, and nerves with ultrasound-guided PVB treatment is more effective than ultrasound-guided PVB treatment alone. Chinese Clinical Trial Registry ChiCTR2200057955.

Ropivacaine pharmacokinetics in the arterial and venous pools after ultrasound-guided continuous thoracic paravertebral nerve block.

Although thoracic paravertebral blockade (TPVB) is employed in thoracic surgery to ensure satisfactory postoperative analgesia, large doses of anesthetics are required and manifestations of local anesthetic systemic toxicity (LAST) may appear. Currently, there are limited data on the pharmacokinetics of ropivacaine after continuous TPVB. The aim of this prospective study was to investigate ropivacaine kinetics, in the arterial and venous pools, after continuous TPVB and assess the risk of LAST. Immediately after induction of general anesthesia, an ultrasound-guided continuous TPVB at T5 or T6 or T7 thoracic level was performed in 18 adult patients subjected to open thoracotomy. A 25-ml single bolus injection of ropivacaine 0.5% was administered through thoracic paravertebral catheter, followed by a 14 ml/h continuous infusion of ropivacaine 0.2% starting at the end of surgery. Quantification of total ropivacaine concentrations was performed using a validated high-performance liquid chromatography method. Population pharmacokinetic models were developed separately for arterial and venous ropivacaine data. The best model was one-compartment disposition with an additional pre-absorption compartment corresponding to thoracic paravertebral space. Gender had a significant effect on clearance, with females displaying lower elimination than males. Some patients had ropivacaine concentrations above the toxic threshold, but none displayed evidence of LAST. Continuous thoracic paravertebral nerve blocks provided adequate postoperative analgesia. Ropivacaine doses at the upper end of clinical use (800 mg/d) did not inflict the manifestations of LAST and provided adequate postoperative pain control. Pharmacokinetic models were developed, and the effect of gender was identified.

Sympathetic dysregulation induced by postnatal intermittent hypoxia.

Exposure to postnatal chronic intermittent hypoxia (pCIH), as experienced in sleep-disordered breathing, is a risk factor for developing cardiorespiratory diseases in adulthood. pCIH causes respiratory instability and motor dysfunction that persist until adult life. In this study, we investigated the impact of pCIH on the sympathetic control of arterial pressure in rats. Neonate male Holtzman rats (P0-1) were exposed to pCIH (6% O2 for 30 seconds, every 10 minutes, 8 h/day) during their first 10-15 days of life, while control animals were maintained under normoxia. In early adult life (P25-40), freely behaving pCIH animals (n = 13) showed higher baseline arterial pressure levels linked to augmented sympathetic-mediated variability than control animals (n = 12, p < 0.05). Using decerebrated in situ preparations, we found that juvenile pCIH rats exhibited a twofold increase in thoracic sympathetic nerve activity (n = 14) and elevated firing frequency of ventromedullary presympathetic neurons (n = 7) compared to control rats (n = 6-7, p < 0.05). This pCIH-induced sympathetic dysregulation was associated with increased HIF-1α (hypoxia-inducible factor 1 alpha) mRNA expression in catecholaminergic presympathetic neurons (n = 5, p < 0.05). At older age (P90-99), pCIH rats displayed higher arterial pressure levels and larger depressor responses to ganglionic blockade (n = 6-8, p < 0.05), confirming the sympathetic overactivity state. pCIH facilitates the vasoconstrictor sympathetic drive by mechanisms associated with enhanced firing activity and HIF-1α expression in ventromedullary presympathetic neurons. This excessive sympathetic activity persists until adulthood resulting in high blood pressure levels and variability, which contribute to developing cardiovascular diseases.

Efficacy of Radiofrequency Thermocoagulation of the Thoracic Sympathetic Nerve versus Chemical Excision in Pain Caused by Raynaud's Disease.

To investigate the effectiveness and safety of computed tomography (CT)-guided radiofrequency thermocoagulation (RFTC) of the thoracic sympathetic nerve versus chemical resection (CTS) for the treatment of pain caused by Raynaud's disease. Patients who underwent CTS or thoracic sympathetic nerve RFTC between March 2012 and March 2021 were enrolled in this retrospective study. There were 28 cases in the alcohol group (Group A) and 44 in the radiofrequency group (Group R). Visual analog scores (VAS) were collected from patients at different time points, as well as preoperative and postoperative finger end perfusion index (PI) and hand temperature (T). The efficiency, postoperative recurrence rate, complications, and improvement in postoperative quality of life were observed in both groups. Pain scores at different follow-up times after surgery decreased in both groups compared to the preoperative period (P < 0.05). Postoperative T and PI were higher in both groups than preoperatively all (P < 0.05). The recurrence rate was higher in the R group than in the A group. Postoperative complications were observed in 13.6% and 25% of patients in groups R and A, respectively. Meanwhile, the postoperative quality of life improved in both groups, but the radiofrequency (RF) group was better than the alcohol group in terms of improvement in quality of life (P < 0.05). Both CT-guided CTS and RFTC of the thoracic sympathetic nerve provided good treatment outcomes. However, the RF group was superior to the alcohol group in terms of complication rate and quality of life improvement.

Cardiovascular Response to Intraneural Right Vagus Nerve Stimulation in Adult Minipig

ObjectiveThis study explored intraneural stimulation of the right thoracic vagus nerve (VN) in sexually mature male minipigs to modulate safe heart rate and blood pressure response. Material and MethodsWe employed an intraneural electrode designed for the VN of pigs to perform VN stimulation (VNS). This was delivered using different numbers of contacts on the electrode and different stimulation parameters (amplitude, frequency, and pulse width), identifying the most suitable stimulation configuration. All the parameter ranges had been selected from a computational cardiovascular system model. ResultsClinically relevant responses were observed when stimulating with low current intensities and relatively low frequencies delivered with a single contact. Selecting a biphasic, charge-balanced square wave for VNS with a current amplitude of 500 μA, frequency of 10 Hz, and pulse width of 200 μs, we obtained heart rate reduction of 7.67 ± 5.19 beats per minute, systolic pressure reduction of 5.75 ± 2.59 mmHg, and diastolic pressure reduction of 3.39 ± 1.44 mmHg. ConclusionHeart rate modulation was obtained without inducing any observable adverse effects, underlining the high selectivity of the intraneural approach.

Differential expression of ITP and ITPL indicate multiple functions in the silkworm Bombyx mori.

Ion transport peptide (ITP) and a longer ITP-like (ITPL) are alternatively spliced insect neuropeptides involved in the regulation of development and water homeostasis. Using in situ hybridisation and immunohistochemistry, we determined site- and stage-specific expression of each peptide in Bombyx mori. Each peptide was differentially expressed, except for the prominent overlapping expression of both peptides in six pairs of the brain neurosecretory cells Ia2. After metamorphosis, ITP appeared in the male-specific neurons of the abdominal neuromere 9 (MAN9) that innervate the reproductive organs. ITPL was detected in a pair of dorsolateral interneurons (IN-DL) in each thoracic and abdominal ganglion, and in the thoracic neurosecretory cells (NS-VTL2) which terminate in the vicinity of the prothoracic gland. Feeding larvae showed ITPL expression in the abdominal neurosecretory cells M5. ITPL was also expressed in the peripheral L1 neurons that project axons into the thoracic and abdominal transverse nerves. Our results suggest that ITP and ITPL exhibit different sex- and stage-specific functions that may include regulation of reproduction and steroid production. For future functional studies, we identified an upstream regulatory region controlling ITP/ITPL expression in the brain and L1 neurons, and prepared stable transgenic line pITP-Gal4.2 using the piggyBac system.

Whole Central and Peripheral Nervous System Mice Dissection.

Animal models represent the workhorse of the neuroscience field. Despite this, today, there is still no step-by-step protocol to dissect a complete rodent nervous system, nor is there a complete schematic representing it that is freely available. Only methods to harvest the brain, the spinal cord, a specific dorsal root ganglion, and the sciatic nerve (separately) are available. Here, we provide detailed pictures and a schematic of the central and peripheral murine nervous system. More importantly, we outline a robust procedure to perform its dissection. The 30 min pre-dissection step allows isolating the intact nervous system within the vertebra with muscles free of viscera and skin. A 2-4 h dissection follows it under a micro-dissection microscope to expose the spinal cord and the thoracic nerves, and finally peel the whole central and peripheral nervous system off the carcass. This protocol represents a significant step forward in studying the anatomy and pathophysiology of the nervous system globally. For example, the dissected dorsal root ganglions from a neurofibromatosis type I mice model can be further processed for histology to unravel changes in tumor progression.

Regional anesthesia for scapulothoracic fixation surgery: Anatomic review and case series.

Scapulothoracic fixation surgery is a surgical intervention used for symptom relief in patients who suffer from scapular dysfunction. To date, there are few reports on the use of regional anesthesia for pain control in patients undergoing this procedure. The nerve supply of the scapula and surrounding tissues is complex and arises from both cervical and thoracic nerve roots. We suggest the use of a combined technique for perioperative pain control in patients undergoing scapulothoracic surgery. After a review of the relevant anatomy, we present four cases using combined regional techniques for postoperative pain control. The techniques utilized include thoracic paravertebral blocks with shoulder blockade, resulting in satisfactory pain control.

Herpes Zoster: a case series with different manifestations

Background: The incidence of herpes zoster appears to correlate inversely with the host's ability to mount a cellular immune response. The disease is characterized clinically by an acute rash with herpetiform blisters on the skin and mucous membranes. This case series presented the different clinical presentations of herpes zoster infection in three patients with different underlying diseases in the ophthalmic, trigeminal, cervical, and thoracic dermatomes. Case Presentation: Three cases of herpes zoster were observed in this case series. The first case involved the ophthalmic division of the trigeminal nerve. The second case involved the cervical nerve, and the last case involved the thoracic nerve. All had undergone varicella infection in childhood and suffered from various states leading to immunosuppression. Tzanck smears were performed in all cases, which showed multinucleated giant cells. After treatment following the herpes zoster protocol, all cases healed without complications. Conclusion: Reactivation of the varicella-zoster virus may occur spontaneously or when host immunity is weakened. Increasing age, a physical trauma (including dental procedures), psychological stress, malignancy, and immunocompromised conditions, including transplant recipients, pregnancy, and HIV infection, are predisposing factors for varicella-zoster virus reactivation.

Virtual reality training and modeling to aid in pre-procedural practice for thoracic nerve root block in the setting of a schwannoma

Virtual reality (VR) is a tool to aid with pre-procedural modeling and practicing for complex procedures with anatomic variation. Here we demonstrate a case of a 64-year-old woman with neuroforaminal compression from a schwannoma that was modeled in VR in order to facilitate pre-procedural training prior to a transforaminal epidural steroid injection. The modeling session allowed for determination of the optimal fluoroscopic angulation to avoid any contact with the mass or nerve root during the procedure. This case study demonstrates a way to incorporate VR in pre-procedural planning and practicing for both learners and experienced interventionalists.