Does subepineural injection damage the nerve integrity?A technical report from four amputated limbs

Local anesthetic (LA) injection outside the sheath in epineural or paraneural connective tissue is considered safe practice among regional anesthesiologists. There is limited evidence as to whether neurological complications occur if LA is injected inside the sheath (subepineural - intraneural). We performed ultrasound guided injections at the level of undivided sciatic nerve in four amputated lower limbs. In two specimens, LA was injected in epineural connective tissue (paraneural tissue) and in another two specimens by penetrating the outer nerve sheath (hyperechoic epineurium). Ultrasonography demonstrated an increase in the size of nerve and macroscopic findings revealed fascicular tracings with sub-epineural injections. Limbs were sent for histological analysis in formalin containers. Pathologist performed the analysis which demonstrated an intact perineurium and a breach in the epineurium. We conclude that sub-epineural injections are unsafe and injection should be done in paraneural tissue to ensure safety and avoid unwanted neurological sequelae after the block.

Does subepineural injection damage the nerve integrity?A technical report from four amputated limbs

Local anesthetic (LA) injection outside the sheath in epineural or paraneural connective tissue is considered safe practice among regional anesthesiologists. There is limited evidence as to whether neurological complications occur if LA is injected inside the sheath (subepineural - intraneural). We performed ultrasound guided injections at the level of undivided sciatic nerve in four amputated lower limbs. In two specimens, LA was injected in epineural connective tissue (paraneural tissue) and in another two specimens by penetrating the outer nerve sheath (hyperechoic epineurium). Ultrasonography demonstrated an increase in the size of nerve and macroscopic findings revealed fascicular tracings with sub-epineural injections. Limbs were sent for histological analysis in formalin containers. Pathologist performed the analysis which demonstrated an intact perineurium and a breach in the epineurium. We conclude that sub-epineural injections are unsafe and injection should be done in paraneural tissue to ensure safety and avoid unwanted neurological sequelae after the block.

Subcoracoid tunnel block as an alternative infraclavicular brachial plexus approach -a case series- / 대한마취과학회지

Background@#Magnetic resonance neurography shows the brachial plexus cords in the subcoracoid tunnel beneath the pectoralis minor. With an ultrasound scan along the brachial line, the brachial plexus cords in the subcoracoid tunnel can be targeted using an in-plane needle approach. We describe this new approach to the infraclavicular block called the “subcoracoid tunnel block.”Case: Twenty patients were administered with the ultrasound-guided subcoracoid tunnel block for the below-elbow surgery. The contact of the needle tip with cords was visible in all 20 patients. With neurostimulation, the posterior cord was identified in 11 (55%) and medial cord in 9 (45%) patients on the first needle pass. The subcoracoid tunnel block was successful in 16 patients (80%). @*Conclusions@#Our case series shows that the subcoracoid tunnel block is an excellent alternative technique for the infraclavicular block. Its advantages include better needle-cord visibility and easy identification of the brachial plexus cords.

India-Based Knee Osteoarthritis Evaluation (iKare): A Multi-Centre Cross-Sectional Study on the Management of Knee Pain and Early Osteoarthritis in India

BACKGROUND: Access to early knee osteoarthritis treatment in low and middle income nations is often believed to be limited. We conducted a cross-sectional study in India to assess prior access to treatment among patients presenting with knee pain to specialist orthopaedic clinics. METHODS: The multi-centre, cross-sectional study included patients presenting with knee pain at 3 hospitals in India. Patients who met the inclusion criteria and provided informed consent completed a questionnaire designed to assess patient demographics, socioeconomic status, knee pain, treatment method, and patient's knowledge on osteoarthritis (OA). Their orthopaedic surgeons also completed a questionnaire on the severity of patient's OA and their recommended treatments. The impact of demographic characteristics on the prescription of treatment options was analyzed using logistic regression. RESULTS: A total of 714 patients met the eligibility criteria and participated in this study. The majority of patients had been experiencing pain for less than 1 year (64.8%) and had previously been prescribed medications (91.6%), supplements (68.6%), and nonpharmacological (81.9%) treatments to manage their knee OA. Current treatment recommendations included oral medications (83.3%), intra-articular injections (29.8%), and surgical intervention (12.7%). Prescription of oral medications was related to younger age, lack of deformities, and lower Kellgren-Lawrence grades (p < 0.01). Patients treated in private hospital settings were more likely to have been previously treated with medications (range, 84.3% to 92.6%; p < 0.01) and physical treatments (range, 61.8% to 84.8%; p < 0.01) than patients treated at government hospitals. CONCLUSIONS: Contrary to the perception, our findings suggest a similar proportion of early knee OA treatment between India and North America.

Assessment of Lumbar Lordosis and Lumbar Core Strength in Information Technology Professionals

STUDY DESIGN: Observational study. PURPOSE: To correlate lumbar lordosis and lumbar core strength in information technology (IT) professionals. OVERVIEW OF LITERATURE: IT professionals have to work for long hours in a sitting position, which can affect lumbar lordosis and lumbar core strength. METHODS: Flexicurve was used to assess the lumbar lordosis, and pressure biofeedback was used to assess the lumbar core strength in the IT professionals. All subjects, both male and female, with and without complaint of low back pain and working for two or more years were included, and subjects with a history of spinal surgery or spinal deformity were excluded from the study. Analysis was done using Pearson's correlation. RESULTS: For the IT workers, no correlation was seen between lumbar lordosis and lumbar core strength (r=-0.04); however, a weak negative correlation was seen in IT people who complained of pain (r=-0.12), while there was no correlation of lumbar lordosis and lumbar core in IT people who had no complains of pain (r=0.007). CONCLUSIONS: The study shows that there is no correlation of lumbar lordosis and lumbar core strength in IT professionals, but a weak negative correlation was seen in IT people who complained of pain.

Assessment of Lumbar Lordosis and Lumbar Core Strength in Information Technology Professionals

STUDY DESIGN: Observational study. PURPOSE: To correlate lumbar lordosis and lumbar core strength in information technology (IT) professionals. OVERVIEW OF LITERATURE: IT professionals have to work for long hours in a sitting position, which can affect lumbar lordosis and lumbar core strength. METHODS: Flexicurve was used to assess the lumbar lordosis, and pressure biofeedback was used to assess the lumbar core strength in the IT professionals. All subjects, both male and female, with and without complaint of low back pain and working for two or more years were included, and subjects with a history of spinal surgery or spinal deformity were excluded from the study. Analysis was done using Pearson's correlation. RESULTS: For the IT workers, no correlation was seen between lumbar lordosis and lumbar core strength (r=-0.04); however, a weak negative correlation was seen in IT people who complained of pain (r=-0.12), while there was no correlation of lumbar lordosis and lumbar core in IT people who had no complains of pain (r=0.007). CONCLUSIONS: The study shows that there is no correlation of lumbar lordosis and lumbar core strength in IT professionals, but a weak negative correlation was seen in IT people who complained of pain.

Demographics of Thoracolumbar Fracture in Indian Population Presenting to a Tertiary Level Trauma Centre

STUDY DESIGN: Prospective, cross-sectional, observational study. PURPOSE: Spine traumata are devastating injuries, which may result in serious disabilities and dire consequences. The current study involves a detailed analysis and description of patients, who were operated at a tertiary care, urban level 1 Spine Centre in India. OVERVIEW OF LITERATURE: Various studies in literature have discussed the epidemiology and patterns of these injuries in trauma patients. However, literature describing the demographic profile and distribution of these traumata in the Indian population is scarce. METHODS: The current study was conducted as a prospective trial involving patients, who were treated at our Spine Centre in India between July 2009 to December 2012. We studied 92 patients with thoraco-lumbar spine fracture, who were operated with short or long segment posterior stabilization. Epidemiological details, pre- and post-hospitalisation care received and other injury pattern factors were studied. RESULTS: Fall from height (46 patients, 50%) was the most common mechanism observed in the patients. Sixty-three percent injuries belonged to AO type A fractures, while 16.2% and 19.4% of the patients had suffered from AO types B and C injuries, respectively. CONCLUSIONS: We identified interesting epidemiological data and prevailing inadequacies in Emergency Spine care management in the study patients. These observations could facilitate implementation of the changes required to improve current standards of patient care.

Post Pregnancy Severe Spinal Osteoporosis with Multiple Vertebral Fractures and Kyphoscoliosis in a Multigravida: A Rare Case with Management

Osteoporosis associated with pregnancy and lactation is a less commonly known condition and often overlooked. The prevalence, exact aetiology and its pathogenesis are unknown. It is commonly seen in first three months after delivery in primigravida. It is often undiagnosed because of it not suspected n and X-rays and densitometry are avoided if possible during pregnancy and lactation. If missed, it can lead to osteoporotic fractures and disability. In this paper, we report a case of a 24-year-old multigravida 4 months after pregnancy with multiple vertebral compression fractures and kyphoscoliosis. Her metabolic workup was normal but bone densitometry revealed severe osteoporosis of the dorso-lumbar spine. Immediate weaning and antiresorptives like bisphosphonates and teriparatide are used as first line drugs to manage postpartum spinal osteoporosis. Our patient presented at 4 month lactation and did not want to wean her infant, so she was treated with total contact orthosis and took vitamin D and calcium. The pain was relieved within 3 months but there was no improvement in bone density. After eight months when the infant was weaned, she was treated with teriparatide. After one year of teriparatide therapy, there were no new fractures and densitometry scores improved.

High Grade Infective Spondylolisthesis of Cervical Spine Secondary to Tuberculosis

Spondylolisthesis coexisting with tuberculosis is rarely reported. There is a controversy whether spondylolisthesis coexists or precedes tuberculosis. Few cases of pathological spondylolisthesis secondary to tuberculous spondylodiscitis have been reported in the lumbar and lumbosacral spine. All cases in the literature presented as anterolisthesis, except one which presented as posterolisthesis of lumbar spine. Spondylolisthesis in the cervical spine is mainly degenerative and traumatic. Spondylolisthesis due to tuberculosis is not reported in the lower cervical spine. The exact mechanism of such an occurrence of spondylolisthesis with tuberculosis is sparsely reported in the literature and inadequately understood. We report a rare case of high grade pathological posterolisthesis of the lower cervical spine due to tubercular spondylodiscitis in a 67-year-old woman managed surgically with a three-year follow-up period. This case highlights the varied and complex presentation of tuberculosis of the lower cervical spine and gives insight into its pathogenesis, diagnosis, and management.