Survey of Sonoanatomic Distances For Lumbar Medial Branch Nerve Blocks in Healthy Volunteers

BACKGROUND: The precise knowledge of anatomy and the region of transverse process (TP) and superior articular processes (AP) and their distance from the skin are important in blocking and treating lumbar facet syndrome. Evaluation of these anatomic distances from 3rd and 5th lumbar vertebrae in both sides and in different body mass index (BMI) in healthy volunteers might improve knowledge of ultrasound (US) lumbar medial branch nerve blocks (LMBB). METHODS: Bilateral US in the 3rd and 5th lumbar vertebrae of 64 volunteers carried out and the distance between skin to TP and skin to AP was measured. These distances were compared on both sides and in different BMI groups. The analysis was done using SPSS 11. Analysis of variance was used to compare the means at three vertebral levels (L3-L5) and different BMI groups. P values less than 0.05 were considered statistically significant. The paired t-test was used to compare the mean distance between skin to TP and skin to AP on both sides. RESULTS: The distance between skin to TP and skin to AP of 3rd vertebrae to 5th vertebrae was increased in both right and left sides (P < 0.001) from up to down. The mean distance from skin to TP were greater on the left side compared to the right in all three vertebral levels from L3 to L5 (P values 0.014, 0.024, and 0.006 respectively). The mean distance from skin to TP and the skin to AP was statistically significant in different BMI groups (P < 0.001). CONCLUSIONS: We found many anatomic distances which may increase awareness of US guided LMBB.

Radiofrequency Thermal Ablation in Painful Myeloma of the Clavicle

A 57-year-old male patient had myeloma. He had severe pain in the left clavicle that did not respond to radiotherapy; therefore, it was treated with radiofrequency thermal ablation (RFTA). Under fluoroscopic guidance, two RF needles at a distance of 1.5 cm from each other were inserted into the mass and conventional radiofrequency (90degrees C and 60 seconds) at two different depths (1 cm apart) was applied. Then, 2 ml of 0.5% ropivacaine along with triamcinolone 40 mg was injected in each needle. The visual analogue pain score (VAS from 0 to 10) was decreased from 8 to 0. In the next 3 months of follow-up, the patient was very satisfied with the procedure and the mass gradually became smaller. There were no complications. This study shows that RFTA could be a useful method for pain management in painful osteolytic myeloma lesions in the clavicle.

Intrathecal injection of magnesium sulfate: shivering prevention during cesarean section: a randomized, double-blinded, controlled study / 대한마취과학회지

BACKGROUND: Regional anesthesia is known to significantly impair thermoregulation and predispose patients to hypothermia. We hypothesized that the addition of an intrathecal injection of magnesium sulfate (MgSO4) to bupivacaine would improve perioperative shivering in female patients undergoing elective caesarean section. METHODS: In a block-randomized, double-blinded, controlled trial 72 patients scheduled for elective caesarean section with spinal anesthesia were separated into two groups. In the treatment group, 2 ml of 0.5% bupivacaine plus 25 mg MgSO4 (0.5 ml) were injected intrathecally, and in the control group 2 ml of 0.5% bupivacaine plus 0.5 ml normal saline were injected intrathecally. Core temperature was measured before and after drug injection at predetermined intervals. Sedation was graded using the Ramsay sedation scale. RESULTS: No significant intergroup differences in appearance of shivering were seen immediately or at 5, 30, 40, 50, 60, and 90 min after block administration. However, at 10, 15, and 20 min post block, there was a significant difference in shivering. The group administered MgSO4 showed lower shivering grades compared with the control group. Core temperature was significantly reduced in the MgSO4 group compared to the normal saline group 30 min after blocking. CONCLUSIONS: Intrathecal injection of MgSO4 improved perioperative shivering in female patients undergoing elective caesarean section.

Sonoanatomic Variation of Pes Anserine Bursa

BACKGROUND: The pes anserine bursa lies beneath the pes anserine tendon, which is the insertional tendon of the sartorius, gracilis, and semitendinosus muscles on the medial side of the tibia, but it can lie in different sites in the medial knee. Accurate diagnosis of the position of the bursa is critical for diagnostic and therapeutic goals. The aim of this study was to evaluate sonoanatomic variations of the pes anserine bursa in the medial knee. METHODS: One hundred seventy asymptomatic volunteers were enrolled in this study. Using ultrasound imaging (transverse approach, 7-13 MHz linear array probe) the sonoanatomic position of the pes anserine bursa and its relation to the pes anserine tendon were evaluated. Additionally, we evaluated the sonoanatomic variation of the saphenous nerve. RESULTS: The position of the pes anserine bursa was between the medial collateral ligament and the pes anserine tendons in 21.2%/18.8% (males/females) of subjects; between the pes anserine tendons and the tibia in 67.1%/64.7% (m/f); and among the pes anserine tendons in 8.2%/12.9% (m/f). No significant differences in the position of the bursa existed between males and females. The saphenous nerve was found within the pes anserine tendons in 77.6%/74.1% (m/f) of subjects, but outside the pes anserine tendons in 18.8%/15.3% (m/f). Visibility of sonoanatomic structures was not related to either gender or BMI. CONCLUSIONS: Ultrasound provides very accurate information about variations in the pes anserine bursa and the saphenous nerve. This suggests that our proposed ultrasound method can be a reliable guide to facilitate approaches to the medial knee for diagnostic and therapeutic objectives.

The Effect of Ultrasound-guided TAPB on Pain Management after Total Abdominal Hysterectomy

BACKGROUND: Incisional pain is particularly troublesome after hysterectomy. A method called transversus abdominis plane block (TAPB) has shown promise in managing postoperative pain. In this study, we evaluated the analgesic efficacy of ultrasound-guided TAPB after hysterectomy at different time points and at each time point separately for 48 hours. METHODS: Forty-two patients (ASA I, II) who were electively chosen to undergo total abdominal hysterectomy were divided into 2 groups, control (group C) and intervention (group I). Twenty-one patients underwent TAPB (group I) and 21 patients received only the standard treatment with a fentanyl pump (group C). Both groups received standard general anesthesia. For patients in group I, following the surgery and before emergence from anesthesia, 0.5 mg/kg of ropivacaine 0.2% (about 20 cc) was injected bilaterally between the internal oblique and transverse abdominis muscles using sonography. Pain scores using the Visual Analogue Scale (VAS) and drug consumption were measured at 2, 6, 12, 24, and 48 hours after TAPB. RESULTS: There were no significant differences in demographics between the two groups. VAS scores appeared to be lower in group I, although there was no interaction with time when we compared mean VAS measurements at different time points between group I and group C (P > 0.05). The amount of fentanyl flow was consistently higher in group C, but when we compared the two groups at each time point separately, the observed difference was not statistically significant (P < 0.053). The incidence of vomiting was 10% in group I and 28% in group C. There were no complaints of itching, and sedation score was 0 to 3. There were no complications. CONCLUSIONS: This study showed that TAPB did not result in a statistically significant decrease in VAS scores at different time points. TAPB did lead to decreased fentanyl flow, but when we compared the two groups at each time point separately, the observed difference was not statistically significant.

Effect of clonidine premedication on blood loss in spine surgery

Blood loss in spine surgery is an important issue, even though it has been understudied compared with hip and knee arthroplasty. In this study, we evaluated the effect of oral clonidine as premedication on blood loss in lumbar spine fusion surgery under anesthesia with propofol and remifentanil. In this double-blind, randomized clinical trial, 30 patients who were undergoing lumbar spine posterior fusion surgery due to traumatic fracture were allocated randomly into 2 groups. The study group [clonidine group] received a 200-microg oral clonidine tablet 60-90 minutes before anesthesia, and the control group received placebo at the same time. Induction and maintenance of anesthesia and the mean target arterial pressure for controlled hypotension with remifentanil were the same in the 2 groups. We compared the amount of intraoperative blood loss, dose of remifentanil/hour administered, need for nitroglycerine to reach the mean target arterial pressure when remifentanil was insufficient, duration of operation, and surgeon's satisfaction of a bloodless field between groups. There was no statistically significant difference between groups in age [P = 0.115], sex [P = 0.439], weight [P = 0.899], operation time [P = 0.2], or American Society of Anesthesiologists physical status score [P = 0.390]. Intraoperative blood loss and remifentanil dose administered per hour in the clonidine group were significantly less than in the control group [P = 0.002 and P = 0.001, respectively], but there was no significant difference in surgeon's satisfaction between groups [P = 0.169]. As an oral premedication, clonidine can reduce surgical blood loss in lumbar spine posterior fusion surgery, even at the same levels of mean arterial pressure [MAP] with the control group. Its use can be studied in more complicated spine surgeries, such as scoliosis and spinal deformity surgeries

[Comparing the analgesic effect pregabalin and gabapentin as premedication in laparoscopic procedures]

Laparoscopic surgery is associated with post operative pain . Optimal pain treatment with minimal side effects is essential for early recovery and mobility in patients undergoing laparoscopic surgery . We compared the analgesic effect Pregabalin and Gabapentin with different doses in these surgical procedures. In a randomized, double blind, ninety patients were allocated to either Group A Pregabalin 300mg, Group B Gabapentin 600mg and Group C Gabapentin 900mg. These were administered 1 h before operation .General anesthesia was performed . We collected data on pain intensity through Visual Analogue Scale [VAS] in recovery, 6, 24 h after operation. Consumption of supp Diclofenac was recorded. p<0.05 was considered statistically significant. Pregabalin 300 mg was significantly more effective in reducing post operative pain up to 24 hours following the surgery [p<0.001] . Furthermore, the amount of analgesic consumption was less in the Pregabalin group [p<0.001]. Consumption analgesic and VAS were more than the other groups in patient who receive Gabapentin 600 mg. Our finding showed that single dose of pregabalin 300mg oral is more effective than Gabapatin on the management of postoperative pain following abdominal laparoscopic surgery. And Pregabalin resulted in reduction in 24 h postoperative analgesic requirements. Gabapentin 900mg decrease VAS and consumption of analgesic significantly

[Comparison of sedative effect of remifentanil with propofol in senile cataract surgery under retrobulbar block]

As general anesthesia is not a suitable choice in elderly ASA>II patients candidate for cataract surgery performored by ophthalmology Residents and lack of cooperation in these patients, sedative effect and hemodynamic status and side effects of two drugs, Remifentanil and propofol are compared in this study. In a Randomized clinical trial 60 patient candidates for cataract surgery were divided in two groups each containing 30 patients. In group A [remifentanil group], patients were sedated with a bolus dose of 0.5 micro g/kg within 1 minute, and maintenance dose of 0.05 micro g/kg/min. In group B [propofol group], patients were sedated with a bolus dose of 0.25 micro g/kg, and maintenance dose of 25 micro g/kg/min. After retrobulbar blockage was performored on all the patients by residents, Hemodynamic responses, including HR, DBP, SBP and O2Sat and sedation level according to MOAA/SS were measured. Modified Observers Assessment of Awareness/Sedation Scale = MOAA/SS. Sedation was deeper in group A [Remifentanil] were statistically meaningful during the measured times after blockage .The heart rate was reduced in group A 20 minutes after blockage and were statistically meaningful [p<0.05]. 7 patients in group A [Remifentanil] had nausea after drug administration [P=0.011]. Remifentanil can induce high level of sedation for patients compare to propofol. But Nausea could be troublesome and in this point propofol has less adverse effect

[Case report: Treatment of burning pain and Post traumatic refractory allodynia in foot digits, with low dose of ketamine]

Frequent simulation and irritation of NMDA receptors by glutamate mediators can lead to burning pain, allodynia and hyperalgesia, even after stopping the irritant factor. Opioid-induced hyperalgesia and peripheral nerve injuries in lower extremities orthopedic surgeries can also make the same symptoms, which sometimes make it difficult to diagnose it from causalgia [type II complex regional pain syndrome]. Post-traumatic neuralgia is not so common, often does not respond well to usual medications and prolongs the patient's stay in hospital. Noting the anatomical and physiological aspects of pain transmission pathways and also role of pain transmission inhibitors via NMDA receptors in pain management, opens us a new window to the role of medicines such as ketamine in prevention and treatment of neuropathic or chronic postoperative pains. We report a case involving refractory neuropathic pain which is eventually controlled with low dose of ketamine

[Sonoanatomy survey of the distance between the suface of the skin and sixth cervical transverse process]

One of interventional procedure in pain specialty is Stellate Ganglion Block. In this study we tried to show more on the sonoanatomy of the area, including the diameter of longus coli muscle and the distance between sixth cervical transverse process and the surface of skin. Obviously, understanding different anatomical locations can help to more successful block and avoid possible complications. This descriptive study was performed on 145 patients who were candidated for elective orthopedic surgery. After patients consented, neck sonography was performed. Demographic data were recorded. Neck circumference, diameter of longus coli muscle and the distance between sixth cervical transverse process and the surface of skin were measured. The average distance from the skin to the transverse process was 2.84 cm and a maximum of 3.7 cm was recorded. Anteroposterior diameter of Longus coli muscle was 0.76 cm, on average. The distance from skin to the transverse process was significantly correlated with body mass index and neck circumference in both sexes. Since the average distance from the skin to the transverse process was 2.84 cm therefore, without any pressure on the skin, inserting the needle more than 2.84 cm has to be with coution, and when it is inserted more than 3.7 cm, it is possibly going off the main path

[Effect of single dose premedication with pregabaline on pain after minor surgery]

Optimal postoperative pain management is necessary after minor general surgery. Although pregabalin had been showed efficacy against neuropathic pain, very limited evidence support its postoperative analgesic efficacy. The aim of this study was to evaluate the analgesic efficacy of premedication with single oral dose of pregabalin for minor general surgery. Sixty patients candidate for minor general surgery under general anesthesia were randomly allocated into the two groups; In intervention group Pregabalin 150mg, and in control group placebo was administered one hour before surgery. Anesthesia method was similar in both groups. If pain score [Visual Analogue Scale, VAS] was more than three, pethidine 25mg intravenous was administrated. VAS, opioid consumption, and side effects were recorded for 24 hours after surgery. Demographic data was not significantly different between two groups. VAS and opioid consumption during the 24 hours postoperative period in pregabalin group was significantly less than the placebo group without any more side effects [p<0.01]. Preoperative administration of single oral dose of pregabalin 150mg reduced post operative pain and opioid consumption for 24 hours following minor general surgery

[ effects of adding ketamine to morphine in patient-controlled intravenous analgesia after orthopedic surgeries]

A routine method to control post-operative pain is patient-controlled intravenous analgesia [PCIA] using opioids. Regarding complications of opioids, it seems necessary to reduce their dosage and to improve the quality of analgesia using adjuvants. We aimed to assess the effect of adding ketamine to morphine in PCIA pumps for post-operative pain control in orthopedic patients. Sixty patients, being 20-60 years old [ASA class I-II] and undergoing orthopedic surgery in lower extremity, were enrolled They had no history of opioid addiction or epilepsy. Our patients were randomly allocated to three groups 20 mg morphine sulfate, 100 mg ketamine plus 20 mg morphine and 200 mg ketamine plus 10 mg morphine in their PCIA pump. The pain score was evaluated using VAS [0-10] and VRS [0-5]; besides the sedation score and the degree of nausea-vomiting were assessed with Ramsay scale [0-5] and N and V score [1-4], respectively. All these measurements were performed 2, 4, 12, 24, and 48 hours postoperatively. The incidence of adverse drug reactions was not different among the three groups [p>0.05], but pain control was significantly better in the second and third group [ketamine plus morphine] in comparison with the first one [p<0.05]. There was no difference in the quality of pain control between the second and the third groups. Also, the need for additional opioid was significantly reduced in the two latter groups compared with the first one [p<0.05]. Adding ketamine to morphine in PCIA pumps would result in better pain control and less need for additional break-through analgesic

Intravenous sufentanil and morphine for post-cardiac surgery pain relief using patient-controlled analgesia [PCA] device: a randomized double-blind clinical trial

Selection of the best analgesic technique in patients undergoing major surgeries can result in lower morbidity and satisfactory postoperative pain relief. In the present study, we tried to compare the effect of morphine and sufentanil on postoperative pain severity and hemodynamic changes by using patient-controlled analgesia [PCA] device in patients who were candidate for coronary artery bypass surgery [CABG]. It was a randomized double-blinded clinical trial in which 120 patients aged 30-65 years, ASA physical status I-Ill, candidate for CABG in Shahid Rajaee hospital in Tehran were included. Before anesthesia, patients were randomly assigned to one of three groups to receive sufentanil [n=40], morphine [n=40] or normal saline [n=40]. After tracheal extubation at intensive care unit, PCA was started by, sufentanil 4mg for the first group, morphine 2mg for the second group and normal saline, at same volume for the third group, intravenously with 10 minute lockout interval. Postoperative pain was evaluated by VAS scale, 1, 6, 12, 18 and 24 hours after extubation and systolic blood pressure, arterial oxygen saturation, PCO2 and PO2 were recorded 24 hours after extubation. VAS scores at rest revealed significantly less pain for patients in sufentanil and morphine groups than normal saline group, throughout the twenty-four hours after operation [P<0.001]. However, there were no significant differences in the means of VAS scores between sufentanil and morphine groups. Among studied hemodynamic parameters, only systolic blood pressure was reduced more in morphine than sufentanil group [P<0.001]. After CABG surgery, administration of intravenous sufentanil and morphine using PCA can lead to similar reduction of postoperative pain severity