Regional anesthesia and pain medicine
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Reg Anesth Pain Med · May 2013
Ultrasound-guided root/trunk (interscalene) block for hand and forearm anesthesia.
Historically, the anterolateral interscalene block--deposition of local anesthetic adjacent to the brachial plexus roots/trunks--has been used for surgical procedures involving the shoulder. The resulting block frequently failed to provide surgical anesthesia of the hand and forearm, even though the brachial plexus at this level included all of the axons of the upper-extremity terminal nerves. However, it remains unknown whether deposition of local anesthetic adjacent to the seventh cervical root or inferior trunk results in anesthesia of the hand and forearm. ⋯ This study did not find evidence to support the hypothesis that local anesthetic injected adjacent to the deepest brachial plexus roots/trunks reliably results in surgical anesthesia of the hand and forearm.
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Reg Anesth Pain Med · May 2013
Cervical spine disease is a risk factor for persistent phrenic nerve paresis following interscalene nerve block.
The use of interscalene blocks (ISBs) for shoulder surgery improves postoperative pain control, reduces recovery room times, and reduces overall hospital stays. The most common and potentially disabling adverse effect associated with ISBs is phrenic nerve paresis. Fortunately, persistent phrenic nerve paresis (PPNP) is rare. ⋯ Patients with PPNP had a significantly higher incidence of cervical spine disease (85.7%) compared with the control group (30.9%), P < 0.01. Persistent phrenic nerve paresis remains a perplexing complication of ISB, and many questions remain unanswered. Our data identify an important risk factor that can aid in the risk stratification of patients undergoing ISB.
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Reg Anesth Pain Med · May 2013
Case ReportsTrialing of intrathecal baclofen therapy for refractory stiff-person syndrome.
Stiff-person syndrome (SPS) is a rare disorder of the central nervous system characterized by stiffness and muscle spasms that may be progressive in nature. When oral medication is inadequate to control muscle spasticity, intrathecal baclofen may be used. We report a patient with severe SPS and glutamate decarboxylase negative [GAD(-)] (note: GAD(-) indicates the patient has no antibodies to GAD), refractory to oral standard therapies. The patient was effectively trialed with an intrathecal catheter and subsequently treated with chronic intrathecal baclofen, which provided significant relief of spasticity symptoms. ⋯ Refractory SPS is difficult to treat and has few therapeutic options. We report a GAD(-) patient with SPS and resulting debilitating spasticity that was refractory to oral medications who underwent successful continuous intrathecal catheter trial of baclofen over 4 days and subsequently went on to implantation of intrathecal pump. The literature reports only 5 cases of GAD(-) SPS patients treated with intrathecal baclofen therapy, and these resulted in poor long-term success. Our patient completed a 4-day trial of intrathecal baclofen titrated to effect before pump implantation. We advocate continuous intrathecal trialing, as opposed to single-injection technique, to possibly better determine the effective therapeutic dose and ensure posttrialing successful therapy.
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Reg Anesth Pain Med · May 2013
The myth of the equiangular triangle for identification of sacral hiatus in children disproved by ultrasonography.
A triangle formed by the sacral hiatus and posterior superior iliac spines (PSISs) has been known as equiangular and has been proposed as a way to help identify the sacral hiatus for a caudal block. In children, however, no feasibility study of this triangle has been performed. We compared the expected sacral hiatus obtained from the equiangular triangle method and the real sacral hiatus confirmed by ultrasound. ⋯ In children, using the equiangular triangle to identify the sacral hiatus may be inappropriate because the actual triangle formed by the sacral hiatus and PSISs is not equiangular.