Bloqueos Nerviosos. Bases Anatómicas del Dolor Somático Abdomino-Pélvico / Nerve Blocks. Anatomy of the Somatic Innervation of the Abdomino-Pelvic Cavity

El dolor abdominal es una de las sintomatologías que afectan con frecuencia la cavidad abdomino-pélvica. Dicha cavidad posee una inervación somática en la que intervienen del séptimo a doceavo nervios intercostales, ramos colaterales y terminales del plexo lumbar y el nervio pudendo; siendo objetivo de este trabajo la descripción anatómica del dolor abdominopélvico a través del plexo lumbar, nervios intercostales y nervio pudendo, sus diferentes patrones y variaciones de conformación, y las implicancias de éstas últimas en las distintas maniobras clínico-quirúrgicas. Se realizó un estudio descriptivo, observacional y morfométrico de la inervación somática de la cavidad abdomino-pélvica, en 50 preparaciones cadavéricas, fijadas en solución de formaldehído, de la Tercera Cátedra de Anatomía, Facultad de Medicina, Universidad de Buenos Aires, entre Agosto/2017-Diciembre/2019. La descripción clásica del plexo lumbar se encontró en 35 casos; la presencia del nervio femoral accesorio en ningún caso; así como también la ausencia del nervio iliohipogástrico en ningún caso; el nervio obturador accesorio se halló en 2 casos; el nervio genitofemoral dividiéndose dentro de la masa muscular del psoas mayor en 6 casos; el nervio cutáneo femoral lateral emergiendo únicamente de la segunda raíz lumbar en 6 casos y por último se encontró la presencia de un ramo del nervio obturador uniéndose al tronco lumbosacro en un caso. Los nervios intercostales y el nervio pudendo presentaron una disposición clásica en todos los casos analizados. Es esencial un adecuado conocimiento y descripción del plexo lumbar, nervios intercostales y nervio pudendo para un adecuado abordaje de la cavidad abdomino-pélvica en los bloqueos nerviosos.

SUMMARY: Abdominal pain is one of the symptoms that affect the abdominal-pelvic cavity. The abdominal-pelvic cavity has a somatic innervation involving the seventh to twelfth intercostal nerves, collateral and terminal branches of the lumbar plexus and the pudendal nerve. The objective of this work is the description of the lumbar plexus, intercostal nerves and pudendal nerve, its different patterns and structure variations, as well as its implications during pain management in patients. A descriptive, observational, and morphometric study of patterns and structure variations of the lumbar plexus, intercostal nerves and pudendal nerve was conducted in 50 formalin-fixed cadaveric dissections of the Third Chair of Anatomy at the School of Medicine in the Universidad de Buenos Aires from August 2017 to December/2019. The standard description of the lumbar plexus was found in 35 cases; accessory femoral nerve was not present in any of the cases; absence of the iliohipogastric nerve was also not found in any case, while the accessory obturating nerve was found in 2 cases; genitofemoral nerve dividing within the muscle mass of psoas in 6 cases; lateral femoral cutaneous nerve emerging only from the second lumbar root in 6 cases and finally, presence of a branch of the obturating nerve was found joining the lumbosacral trunk in one case. The pudendal and intercostal nerve patterns presented a typical pathway in all cases. Adequate knowledge and description of the lumbar plexus, intercostal nerves and pudendal nerve is essential for an adequate approach of the abdominal-pelvic cavity in nerve blocks.

Circumpsoas block - an anterior myofascial plane block for lumbar plexus elements: case report

Abstract In an attempt to improvise the analgesia in patients with femoral fractures, we aimed at depositing local anesthetic deep to anterior psoas fascia (APf) under ultrasound (US) guidance to block lumbar plexus elements which emerge lateral, anterior, and medial to the psoas major muscle. We termed this as circumpsoas block (CPB). Clinical and computed tomography contrast studies revealed that a continuous CPB infusion with a catheter provided a reliable block of the lumbar plexus elements. No adverse were events noted. We conclude that US guided CPB is a reliable technique for managing postoperative pain after surgery of femur fractures.

Dorsal Root Entry Zone Lesioning: Systematic Review

Introduction Dorsal root entry zone (DREZ) leasioning (DREZ-otomy) is considered an effective treatment for chronic pain due to spinal cord injuries, brachial and lumbosacral plexus injuries, postherpetic neuralgia, spasticity, and other conditions. The objective of the technique is to cause a selective destruction of the afferent pain fibers located in the dorsal region of the spinal cord. Objective To identify and review the effectiveness and the main aspects related to DREZ-otomy, as well as the etiologies that can be treated with it. Methods The PubMed, MEDLINE and LILACS databases were used as bases for this systematic review, having the impact factor as the selection criteria. The 23 selected publications, totalizing 1,099 patients, were organized in a table for systematic analysis. Results Satisfactory pain control was observed in 70.1% of the cases, with the best results being found in patients with brachial/lumbosacral plexus injury (70.8%) and the worst, in patients with trigeminal pain (40% to 67%). Discussion Most of the published articles observed excellent results in the control of chronic pain, especially in cases of plexus injuries. Complications are rare, and can be minimized with the use of new technologies for intraoperative monitoring and imaging. Conclusion DREZ-otomy can be considered a great alternative for the treatment of chronic pain, especially in patients who do not tolerate the side effects of the medications used in the clinical management or have refractory pain.

Morphometry of spinal nerve composition and thicknesses of lumbar plexus nerves for use in clinical applications / Morfometría de la composición del nervio espinal y espesores de nervios del plexo lumbar para su uso en aplicaciones clínicas

SUMMARY: The aim of this study was to clarify the diverse spinal compositions of the branches of the lumbar plexus in terms of their prevalence rates and thicknesses. Thirty lumbar plexuses extracted from Korean adults were used in this study. The nerve fascicles were separated and traced with the aid of a surgical microscope. The thickness of each spinal nerve component was calculated based on the mean of the largest and smallest diameters using digital calipers under the surgical microscope. The most common patterns of the spinal composition of the branches of the lumbar plexus were as follows: The iliohypogastric nerve (IHN) and the ilioinguinal nerve (IIN) arose from the ventral ramus of the first lumbar nerve (L1), the genitofemoral nerve (GFN) arose from the anterior division of the ventral ramus of the second lumbar nerve (L2), and the lateral femoral cutaneous nerve (LFCN) arose from the posterior division of the ventral ramus of theL2, the femoral nerve (FN) arose from the posterior division of the ventral ramus of L2-the fourth lumbar nerve (L4), with the thickest spinal component derived from the third lumbar nerve (L3), and the obturator nerve (OBN) arose from the anterior division of the ventral ramus of L2-L4, with the thickest spinal component derived from L3. However, when L5 constituted the FN and OBN, the thickest spinal components of the FN and OBN was L4. This morphometric study has measured the thicknesses of diverse spinal components that constitute the branches of the lumbar plexus after separating the nerve fascicles. The thicknesses of the various spinal components of these branches can be compared in order to understand which make the main and minor contributions to the lower limb.

RESUMEN: El objetivo de este estudio fue evaluar las diversas composiciones espinales de los ramos del plexo lumbar en cuanto a sus tasas de prevalencia y grosor. Se utilizaron treinta plexos lumbares extraídos de individuos adultos coreanos. Se separaron y trazaron los fascículos nerviosos por medio de un microscopio quirúrgico. El grosor de cada componente del nervio espinal se calculó con base en la media de los diámetros mayor y menor utilizando calibradores digitales bajo el microscopio. Los patrones más comunes de la composición espinal de los ramos del plexo lumbar fueron los siguientes: el nervio iliohipogástrico (NIH) y el nervio ilioinguinal (NII) surgieron del ramo ventral del primer nervio lumbar (L1). El nervio genitofemoral (NGF) surgió de la división anterior del ramo ventral del segundo nervio lumbar (L2). El nervio cutáneo femoral lateral (NCFM) surgió de la división posterior del ramo ventral L2. El nervio femoral (NF) surgió de la división posterior del ramo ventral de L2. El cuarto nervio lumbar (L4), con el componente espinal más grueso derivado del tercer nervio lumbar (L3) y el nervio obturador (NOB) surgieron de la división anterior del ramo ventral de L2-L4, con el componente espinal más grueso derivado de L3. Sin embargo, cuando L5 constituía el NF y NOB, los componentes espinales más gruesos del NF y NOB eran de L4. Este estudio morfométrico analizó los espesores de diversos componentes espinales que constituyen las ramas del plexo lumbar después de separar los fascículos nerviosos. Es posible comparar los espesores de los diversos componentes espinales de estos ramos para comprender las contribuciones principales y menores al miembro inferior.

Origin and distribution of the lumbosacral plexus anatomy in van cats / Origen y distribución de la anatomía del plexo lumbosacro en gatos van

SUMMARY: The innervation of the pelvic limbs of the Van cat is investigated in this research. The origins of the nerves, the innervated muscles and nerve diameters were shown in a table. Five cat cadavers were used in the study. The pudendal nerve originated from the S1-S2 spinal nerves. The femoral nerve consisted of the ventral branches of the 5th and 6th lumbar nerves in 4 cats The ischiatic nerve was composed of the 6th and 7th lumbar (L6-L7) and S1 spinal nerves in all cadavers. The ischiatic nerve was the thickest branch of sacral plexus (the average diameter on the right side was 3.31 ± 0.27 mm and the average diameter on the left side was 3.28 ± 0.29 mm). The lumbosacral plexus was formed by the ventral branches of the L4-S3 spinal nerves. N.genitofemoralis consisted of only the ventral branches of L4 in all cadavers. N. femoralis did not give rise to a branch to the m. iliopsoas. N.plantaris lateralis was found to give a branch to the 3th finger. The quadriceps femoris muscles did not take any branches from either the ischiadicus nerve or the pudendal nerve. The obturator nerve did not receive any branches from the L4 spinal nerves. There was no branch to the skin from the caudal gluteal nerve. The thinnest nerve was the pudendal nerve. Due to the scarcity of studies on the lumbosacral plexus of cats, it is thought that this study will complete a gap in the field of veterinary anatomy.

RESUMEN: En esta investigación se estudió la inervación de los miembros pélvicos del gato Van. Los orígenes de los nervios, los músculos inervados y los diámetros de los nervios son mostrados en una tabla. En el estudio se utilizaron cinco cadáveres de gatos. En cuatro gatosel nervio pudendo se originaba a partir de los nervios espinales S1-S2. El nervio femoral consistió en los ramos ventrales de los nervios lumbares quinto y sexto. El nervio isquiático estaba compuesto por los nervios espinales sexto y séptimo lumbar (L6-L7) y S1 en todos los cadáveres. El nervio isquiático era el ramo más grueso del plexo sacro (el diámetro medio del lado derecho medía de 3,31 ± 0,27 mm y el diámetro medio izquierdo 3,28 ± 0,29 mm). El plexo lumbosacro estaba formado por los ramos ventrales de los nervios espinales L4-S3. N. genitofemoralis constaba solo de las ramas ventrales de L4 en todos los cadáveres. N. femoralis no dio lugar a un ramo a la m. iliopsoas. Los músculos del cuádriceps femoral no tomaron ningún ramo ni del nervio isquiático ni del nervio pudendo. El nervio obturador no recibió ramos de los nervios espinales L4. No existían ramos a la piel desde el nervio glúteo caudal. El nervio más delgado fue el nervio pudendo. Debido a la escasez de estudios sobre el plexo lumbosacro de los gatos, este estudio completará un vacío en el campo de la anatomía veterinaria.

Incidence of epidural spread after Chayens approach to lumbar plexus block: a retrospective study / Incidência de dispersão peridural após bloqueio do plexo lumbar com técnica de Chayen: estudo retrospectivo

Abstract Background and objectives: The lumbar plexus block (LPB) is a key technique for lower limb surgery. All approaches to the LPB involve a number of complications. We hypothesized that Chayen's approach, which involves a more caudal and more lateral needle entry point than the major techniques described in the literature, would be associated with a lower rate of epidural spread. Method: We reviewed the electronic medical records and chart of all adult patients who underwent orthopedic surgery for Total Hip Arthroplasty (THA) and hip hemiarthroplasty due to osteoarthritis and femoral neck fracture with LPB and Sciatic Nerve Block (SNB) between January 1, 2002, and December 31, 2017, in our institute. The LPB was performed according to Chayen's technique using a mixture of mepivacaine and levobupivacaine (total volume, 25 mL) and a SNB by the parasacral approach. The sensory and motor block was evaluated bilaterally during intraoperative and postoperative period. Results: A total number of 700 patients with American Society of Anesthesiologists (ASA) physical status I to IV who underwent LPB met the inclusion criteria. The LPB and SNB was successfully performed in all patients. Epidural spread was reported in a single patient (0.14%;p < 0.05), accounting for an 8.30% reduction compared with the other approaches described in the literature. No other complications were recorded. Conclusions: This retrospective study indicates that more caudal and more lateral approach to the LPB, such as the Chayen's approach, is characterized by a lower epidural spread than the other approach to the LPB.

Resumo Justificativa e objetivos: O bloqueio do plexo lombar (BPL) é uma técnica fundamental para a cirurgia de membros inferiores. Todas as abordagens do BPL são associadas a uma série de complicações. Nossa hipótese foi de que a abordagem de Chayen, que envolve um ponto de entrada da agulha mais caudal e mais lateral do que as principais técnicas descritas na literatura, estaria associada a menor incidência de dispersão peridural. Método: Revisamos os prontuários médicos eletrônicos e em papel de todos os pacientes adultos submetidos à artroplastia total do quadril (ATQ) e hemiartroplastia do quadril devido a osteoartrite ou fratura do colo do fêmur empregando-se BPL associado ao bloqueio do nervo ciático (BNC), entre 1 de janeiro de 2002 e 31 de dezembro de 2017 em nossa instituição. Realizamos o BPL usando a técnica de Chayen e uma mistura de mepivacaína e levobupivacaína (volume total de 25 mL) e o BNC pela abordagem parassacral. Testes sensorial e motor bilaterais foram realizados no intra e pós-operatório. Resultados: Os critérios de inclusão foram obedecidos pelo total de 700 pacientes classe ASA I a IV submetidos ao BPL. Os BPL e BNC foram realizados com sucesso em todos os pacientes. A dispersão peridural foi relatada em um único paciente (0,14%; p < 0,05), representando uma redução de 8,30% quando comparada às outras abordagens descritas na literatura. Nenhuma outra complicação foi registrada. Conclusões: Este estudo retrospectivo indica que a abordagem mais caudal e mais lateral do BPL, como a técnica de Chayen, é caracterizada por menor dispersão peridural do que outras abordagens do BPL.

Minilaparoscopic lumbar sympathectomy with 3 mm instruments for plantar hyperhidrosis / Simpatectomia lombar endoscópica com microinstrumental de 3 mm para hiperidrose plantar

Abstract Severe palmoplantar hyperhidrosis affects about 1.5-2.8% of the general population. Plantar hyperhidrosis (PHH) is related to foot odor, cold feet, skin lesions and infections, and even instability when walking. Endoscopic Lumbar Sympathectomy (ELS) is the treatment of choice for this condition. However, few surgeons have used this technique over the past 20 years because of its technical difficulty. Two and 3 mm instruments, rather than the standard 5 mm instruments, have been used to improve the results of several standard laparoscopic procedures. Use of these minilaparoscopic instruments to perform ELS so far has not yet been published. We describe a technique for ELS using minilaparocopic instruments, which we have used for our last 70 cases and has become our standard technique. The aim of this study is to demonstrate the feasibility of this technique and its advantages compared to the conventional technique.

Resumo A hiperidrose palmoplantar grave afeta cerca de 1,5-2,8% da população geral. A hiperidrose plantar está relacionada a odor dos pés, pés frios, lesões cutâneas, infecções, e até instabilidade da marcha. A simpatectomia lombar endoscópica (endoscopic lumbar sympathectomy, ELS) é o tratamento de escolha para essa condição; entretanto, tem sido utilizada por poucos cirurgiões nos últimos 20 anos, devido à sua dificuldade técnica. Instrumentos de 2 e 3 mm em vez de 5 mm vêm sendo utilizados para melhorar os resultados de vários procedimentos laparoscópicos padrão. O uso desses instrumentos para realizar ELS ainda não foi descrito. Descrevemos a técnica para ELS usando microinstrumentos, a qual vem sendo usada para os nossos últimos 70 casos, pois passou a ser nosso procedimento padrão. O objetivo deste estudo é apresentar a experiência com essa modificação técnica, assinalando as vantagens em relação à técnica tradicional.

Bloqueos de extremidad inferior / Lower extremity blocks

Lower limb blocks are described with emphasis on distribution according to sensitive distribution and its sonoanatomy.

Se describen los bloqueos de la extremidad inferior haciendo énfasis en la distribución de acuerdo a distribución sensitiva y a su sonoanatomia.

Report of an inferior rectal nerve variant arising from the S3 ventral ramus / 대한해부학회지

In surgical approaches to the perineum in general and anal region specifically, considering the possible variations of the inferior rectal nerve is important for the surgeon. Normally, the inferior rectal nerve originates as a branch of the pudendal nerve. However, during routine dissection, a variant of the inferior rectal nerve was found where it arose directly from the third sacral nerve ventral ramus (S3). Many cases have described the inferior rectal nerve arising independently from the sacral plexus, most commonly from the fourth sacral nerve root (S4); however, few cases have reported the inferior rectal nerve arising from S3. Herein, we describe a variant of the inferior rectal nerve in which the nerve arises independently from the sacral plexus.

A multiply split femoral nerve and psoas quartus muscle / 대한해부학회지

Peripheral Neuropathies in Patients with Rhabdomyolysis: Clinical Characteristics and Electrodiagnostic Findings in the Acute/Subacute Stage

BACKGROUND: Rhabdomyolysis is a syndrome caused by injury to skeletal muscle and characterized by myalgia and swelling of the affected muscles. Peripheral nerve injury rarely occurs in patients with rhabdomyolysis. METHODS: We reviewed the medical records of 8 consecutive patients with peripheral neuropathies associated with rhabdomyolysis. We assessed the clinical characteristics and electrodiagnostic findings of eight patients. RESULTS: In seven patients, rhabdomyolysis occurred after prolonged immobilization. In one patient, blunt trauma was a cause of rhabdomyolysis. All patients presented with weakness and paresthesia in lower extremities and electrodiagnostic tests showed peripheral nerve injury suggesting sciatic neuropathy or lumbosacral plexopathy. Although rhabdomyolysis itself recovered completely in all patients, neurologic deficits from neuropathy recovered partially and slowly. CONCLUSIONS: Sciatic nerve or lumbosacral plexus was injured in all eight patients. Among the various causes of rhabdomyolysis, prolonged immobilization is associated with development of peripheral neuropathy.

Perioperative lumbar plexus block and cardiac ischemia in patients with hip fracture: randomized clinical trial / Bloqueio perioperatório do plexo lombar e isquemia cardíaca em pacientes com fratura de quadril: ensaio clínico randomizado

Abstract Background Perioperative myocardial ischemia is common among patients undergoing hip fracture surgery. Our aim is to evaluate the efficacy of perioperative continuous lumbar plexus block in reducing the risk of cardiac ischemic events of elderly patients undergoing surgery for hip fractures, expressed as a reduction of ischemic events per subject. Methods Patients older than 60 years, ASA II-III, with risk factors for or known coronary artery disease were enrolled in this randomized controlled study. Patients were randomized to conventional analgesia using opioid intravenous patient-controlled analgesia or continuous lumbar plexus block analgesia, both started preoperatively and maintained until postoperative day three. Continuous electrocardiogram monitoring with ST segment analysis was recorded. Serial cardiac enzymes and pain scores were registered during the entire period. We measured the incidence of ischemic events per subject registered by a continuous ST-segment Holter monitoring. Results Thirty-one patients (intravenous patient-controlled analgesia 14, lumbar plexus 17) were enrolled. There were no major cardiac events during the observation period. The number of ischemic events recorded by subject during the observation period was 6 in the lumbar plexus group and 3 in the intravenous patient-controlled analgesia group. This difference was not statistically significant (p = 0.618). There were no statistically significant differences in the number of cases with increased perioperative troponin values (3 cases in the lumbar plexus group and 1 case in the intravenous patient-controlled analgesia group) or in terms of pain scores. Conclusions Using continuous perineural analgesia, compared with conventional systemic analgesia, does not modify the incidence of perioperative cardiac ischemic events of elderly patients with hip fracture.

Resumo Justificativa A isquemia miocárdica perioperatória é comum em pacientes submetidos à cirurgia de fratura de quadril. Nosso objetivo foi avaliar a eficácia do bloqueio perioperatório contínuo do plexo lombar na redução do risco de eventos cardíacos isquêmicos em pacientes idosos submetidos à cirurgia para fraturas de quadril, expresso como uma redução de eventos isquêmicos por indivíduo. Métodos Pacientes com mais de 60 anos de idade, ASA II-III com fatores de risco para ou com doença coronariana conhecida foram incluídos neste estudo controlado e randomizado. Os pacientes foram aleatorizados para analgesia convencional usando analgésicos opioides para administração de analgesia intravenosa controlada pelo paciente (Intravenous Patient-Controlled Analgesia - IVPCA) ou analgesia contínua com o bloqueio do Plexo Lombar (PL), ambas iniciadas no pré-operatório e mantidas até o terceiro dia de pós-operatório. Monitoração contínua de ECG com análise do segmento ST foi registrada. Enzimas cardíacas seriadas e escores de dor foram registrados durante todo o período. Medimos a incidência de eventos isquêmicos por indivíduo registrados com monitoração contínua do segmento ST via Holter. Resultados Trinta e um pacientes (IVPCA 14, PL 17) foram incluídos. Não houve eventos cardíacos sérios durante o período de observação. O número de eventos isquêmicos registrados por sujeito durante o período de observação foi de seis no grupo PL e três no grupo IVPCA. Essa diferença não foi estatisticamente significativa (p = 0,618). Não houve diferenças estatisticamente significativas no número de casos com aumento dos valores de troponina no perioperatório (três casos no grupo LP e um caso no grupo IVPCA) ou em termos de escores de dor. Conclusões O uso da analgesia perineural contínua comparado ao da analgesia sistêmica convencional não modifica a incidência de eventos isquêmicos cardíacos no período perioperatório de pacientes idosos com fratura de quadril.

Origin and distribution of femoral nerves in swine (Sus scrofa domesticus) fetuses from crosses of Dan Bred and AGPIC-337 lines / Origem e distribuição dos nervos femorais em fetos suínos (Sus scrofa domesticus - linneaus, 1758) do cruzamento das linhagens Dan Bred e AGPIC337

The objective of this work was to assess the origin and distribution of femoral nerves in 30 swine fetuses from crosses of Dan Bred and AGPIC-337 lines. Thirty animals­fifteen males and fifteen females­from the collection of the Faculty of Veterinary Medicine's Animal Anatomy Laboratory of the Federal University of Uberlândia, Uberlândia MG, Brazil, were used. The animals were fixed by injecting a 10% aqueous formaldehyde solution into the descending aorta artery and thoracic, abdominal, pelvic and intramuscular cavities. The specimens were then submerged in a solution with the same concentration. These animals have five to seven lumbar vertebrae. The number of lumbar vertebrae was six in 96.67% and seven in 3.33% of the animals. The femoral nerve originated from the L4 and L5 (66.67%), L5 and L6 (26.67%) and L3 and L4 (6.66%) lumbar vertebrae. It sent branches to the psoas major, psoas minor, iliac, pectineus, and quadriceps femoris muscles in all animals, to the sartorius in 43.33% and to the gracilis in 6.66% of animals. No marked differences were found in the characteristics of origin and distribution of the femoral nerve between the swine fetuses from crosses of Dan Bred and AGPIC-337 lines and the animals described in the literature.

Objetivou-se estudar a origem e distribuição dos nervos femorais em 30 fetos suínos oriundos do cruzamento das linhagens Dan Bred e AGPIC337. Foram utilizados 30 animais, quinze machos e quinze fêmeas, pertencente ao acervo do laboratório de Anatomia Animal da Faculdade de Medicina Veterinária da Universidade Federal de Uberlândia. A fixação dos animais se deu por meio de injeção de solução aquosa de formaldeído a 10% na artéria aorta parte descendente, cavidades torácica, abdominal, pélvica e intramusculares, em seguida, os espécimes foram submersos em solução contendo a mesma concentração. Esses animais possuem cinco a sete vértebras lombares. Em 96,67% dos animais o número de vértebras lombares foi seis e em 3,33% sete. O nervo femoral originou-se de L4 e L5 (66,67%), L5 e L6 (26,67%) e L3 e L4 (6,66%). Emitiu ramos para os músculos psoas maior, psoas menor, ilíaco, pectíneo, quadríceps femoral em 100% dos casos, 43,33% para o sartório e 6,66% para o grácil. Nota-se que não foram observadas diferenças marcantes nas características tanto na origem como na distribuição do nervo femoral entre os fetos de suínos oriundos do cruzamento das linhagens Dan Bred e AGPIC337 e os animais da literatura consultada

Neurolitic block of the lumbar sympathetic chain improves chronic pain in a patient with critical lower limb ischemia / Bloqueio neurolítico da cadeia simpática lombar melhora dor crônica em paciente portadora de isquemia crítica de membro inferior

Abstract Background and objectives Sympathectomy is one of the therapies used in the treatment of chronic obstructive arterial disease (COAD). Although not considered as first-line strategy, it should be considered in the management of pain difficult to control. This clinical case describes the evolution of a patient with inoperable COAD who responded properly to the lumbar sympathetic block. Case report A female patient, afro-descendant, 69 years old, ASA II, admitted to the algology service due to refractory ischemic pain in the lower limbs. The patient had undergone several surgical procedures and conservative treatments without success. Vascular surgery considered the case as out of therapeutic possibility, unless limb amputation. At that time, sympathectomy was indicated. After admission to the operating room, the patient was monitored, positioned and sedated. The blockade was performed with the aid of radioscopy, bilaterally, at L2-L3-L4 right and L3 left levels. On the right side, at each level cited, 3 mL of absolute alcohol with 0.25% bupivacaine were injected without vasoconstrictor, and on the left side only local anesthetic. The procedure was performed uneventfully. The patient was discharged with complete remission of the pain. Conclusion Neurolitic block of the lumbar sympathetic chain is an effective and safe treatment option for pain control in patients with critical limb ischemia patients in whom the only possible intervention would be limb amputation.

Resumo Justificativa/objetivos A simpatectomia é uma das terapêuticas usadas no tratamento dadoença arterial obstrutiva crônica (DAOP). Embora não seja considerada como estratégia de primeira linha, deve ser lembrada no manejo dos quadros de dor de difícil controle. Este caso clínico descreve a evolução de uma paciente portadora de DAOP inoperável que respondeu adequadamente ao bloqueio simpático lombar. Relato de caso Paciente do sexo feminino, parda, 69 anos, estado físico II, acompanhada no serviço de algologia devido a dor isquêmica refratária em membros inferiores. A paciente já havia sido submetida a diversas abordagens cirúrgicas e tratamentos conservadores, sem sucesso. A cirurgia vascular considerou o caso como fora de possibilidade terapêutica, a não ser amputação do membro. Nesse momento, foi indicada simpatectomia. Após admissão no centro cirúrgico, a paciente foi monitorada, posicionada e sedada. O bloqueio foi feito com auxílio da radioscopia, bilateralmente, nos níveis L2-L3-L4 à direita e L3 à esquerda. Do lado direito, em cada nível citado, foram injetados 3 mL de álcool absoluto com bupivacaína 0,25% sem vasoconstritor e do lado esquerdo somente o anestésico local. O procedimento foi feito sem intercorrências. A paciente recebeu alta com completa remissão da dor. Conclusão O bloqueio neurolítico da cadeia simpática lombar é uma opção de tratamento eficaz e segura para controle da dor em pacientes portadores de isquemia crítica, nos quais a única intervenção possível seria a amputação do membro.

Continuous lumbar plexus block reduces the incidence of early postoperative cognitive dysfunction in elderly patients undergoing hip arthroplasty / 中南大学学报(医学版)

To observe the impacts of continuous lumbar plexus block (CLPB) on postoperative cognitive dysfunction (POCD) in elderly patients undergoing hip arthroplasty.
 Methods: Sixty elderly patients scheduled for hip arthroplasty with general anesthesia, were randomly allocated into a CLPB group and a PCIA group (n=30 each). In the CLPB group, lumbar plexus block was performed before trachea intubation, and CLPB was used for postoperative analgesia. In the PCIA group, intravenous analgesia was controlled in patients after operation. Visual Analogue Scale (VAS) at 12, 24, and 48 h after operation was recorded. Mini-Mental State Examination (MMSE) scale was used to evaluate the cognitive dysfunction at the 1st day before operation (D0) and at the 1st (D1), 3rd (D3), and 7th (D7) days after operation and the occurrence of POCD was recorded. S-100β concentrations were detected by ELISA at D1, D3, and D7. Postoperative adverse events were recorded.
 Results: VAS scores at 12, 24, and 48 h after operation in the CLPB group were significantly lower than those in the PCIA group (P<0.05). Compared with the PCIA group, the MMSE scores were significantly higher (P<0.05), and the incidence of POCD at D1 and D3 was obviously reduced in the CLPB group (P<0.05). S-100β concentration at D1 and D3 in the CLPB group was significantly lower than that in the PCIA group (P<0.05).
 Conclusion: Application of CLPB in elderly patients undergoing hip arthroplasty could obviously relieve their postoperative pain, inhibit the production of S-100β, and reduce the incidence of early postoperative cognitive dysfunction.