Serratus Posterior Superior Intercostal Plane Block: A Technical Report on the Description of a Novel Periparavertebral Block for Thoracic Pain.

Background and objective We report a novel block technique aimed to provide thoracic analgesia: the serratus posterior superior intercostal plane (SPSIP) block. Design A cadaveric evaluation along with a retrospective case series evaluating the potential analgesic effect of the SPSIP block. This study included one unembalmed cadaver and five patients. Interventions Bilateral ultrasound-guided SPSIP block was used on cadavers with 30 mL of methylene blue 0.5% on each side; single-injection SPSIP blocks were used in patients. To measure results, dye spread was used in the cadaver, and dermatomal/pain score evaluation was used in patients. Main results Anatomical investigation in one unembalmed cadaver shows that its mechanism of action covers the rhomboid major muscle, erector spinae muscle, the deep fascia of the subscapularis/serratus anterior muscles, and intercostal nerves. In our patients, SPSIP resulted in an almost complete sensory block in the back of the neck, shoulder, and hemithorax. Conclusion Our cadaveric study shows extensive dye spread from C7 to T7. Patients who were administrated SPSIP block reported consistent dermatomal blockade from C3 to T10 levels of the hemitorax. The SPSIP block seems to be a safe, simple, and effective technique for thoracic analgesia.

Ultrasound-guided Erector Spinae Plane Block for the Management of Herpes Zoster Pain: Observational Study.

Background Herpes zoster is caused by the reactivation of latent varicella-zoster virus, which promotes acute and chronic pain that may interfere with daily activities and reduce the quality of life. Ultrasound-guided erector spinae plane (ESP) blocks are used for a wide variety of indications in the management of acute, chronic, and postoperative pain. Our aim was to evaluate the efficacy of ultrasound-guided erector spinae plane blocks for the management of pain in herpes zoster. Methods The medical records of 34 patients with acute or chronic pain during herpes zoster between May 2017 and June 2018 were investigated at two pain clinic centers. The patients received ultrasound-guided erector spinae plane block: We performed a single injection for the patients having acute pain and a continuous block for the patients having chronic pain. Patient characteristics, block characteristics (needle insertion level, catheter, or single insertion), the volume of given local anesthetics, the intensity of pain before and after the block procedure using a numerical rating score (NRS) between 0 and 10, and the duration of analgesia were evaluated. Results All patients reported a remarkable and rapid resolution of pain immediately after the block procedure. Median (min-max) NRS score before the block procedure was 9 (4-10). The median (min-max) NRS score was 1.5 (0-7) after the block procedure. The difference was found to be statistically significant (p<0.0001). NRS score after the third month was 1 (0-3); the difference is statistically significant (p=0.002). The median value of analgesia time (min-max) was 18 (3-24) hours. Conclusion Our preliminary experience demonstrated that an ESP block provided sufficient analgesia in acute herpetic pain. A combination of ESP block, pregabalin, and tramadol was also effective within the three-months-period after the block performance.

Decreased incidence of headache after unintentional dural puncture in patients with cesarean delivery administered with postoperative epidural analgesia.

PURPOSE: To investigate how subsequent placement of a catheter into the epidural space after unintentional dural puncture for postoperative analgesia for 36-72 h affected the incidence of post-dural puncture headache (PDPH). METHODS: The records of 52 parturients who had had accidental dural puncture in cesarean delivery were reviewed. The parturients were assigned to two groups. Twenty-eight parturients were assigned to the study group, in whom an epidural catheter was inserted and was used for anesthesia and postoperative analgesia. Twenty-four parturients were assigned to the control group, in whom spinal anesthesia (n = 20) or general anesthesia (n = 4) was applied. For postoperative analgesia in patients with incision pain above visual analog scale (VAS) 3, 3 mg morphine in 15 ml saline was administered through the epidural catheter in the study group, while intramuscular meperidine or tramadol was administered in the control group. Once PDPH was observed, conservative treatment was tried first. If the headache persisted despite conservative treatment, an epidural blood patch was applied through the catheter or a reinserted epidural needle. RESULTS: The study group demonstrated significant reduction of the incidence of PDPH and reduction in the indication for an epidural blood patch compared to the control group (7.1% vs 58% [P = 0.000] and 3.6% vs 37.5% [P = 0.002], respectively). CONCLUSION: Subsequent catheter placement into the epidural space after unintentional dural puncture in cesarean delivery and leaving the catheter for postoperative analgesia for 36-72 h may reduce the incidence of PDPH.

A plantar flexion response to nerve stimulation indicates needle misplacement in the epidural/spinal space during psoas compartment block.

We report two cases of plantar flexion due to epidural misplacement of the needle during psoas compartment block, providing a response feedback for needle position during this procedure. In one case, the response occurred contralaterally, and in the other bilaterally. In the first patient, the cause of contralateral plantar flexion could not be determined and no injection was made. In the second patient, the anteriorposterior-fluoroscopic image showed that the tip of the needle was placed at the midline of the column. At this point, 3 ml of radiopaque medium was injected, and it diffused throughout the epidural space. Subsequently, single-shot epidural anesthesia was achieved by injection through this needle.

The role of succinylcholine in the prevention of the obturator nerve reflex during transurethral resection of bladder tumors.

OBJECTIVE: To present our 8 year experience in the prevention of the obturator nerve reflex during transurethral resection of bladder tumors. METHODS: This study was performed in Ataturk University Hospital between 1999 and 2007. We retrospectively reviewed the records of 89 patients with inferolateral bladder tumors, who underwent transurethral resection under epidural or general anesthesia and requested obturator nerve reflex inhibition. Epidural anesthesia was administered to 57 patients, while the remaining 32 patients underwent general anesthesia via mask; and succinylcholine was administered prior to resection. RESULTS: Of the 57 patients received epidural anesthesia, 18 were diagnosed as inferolateral bladder tumors during endoscopy and had to undergo general anesthesia. Obturator nerve block was attempted preoperatively in 39 patients. However, a nerve identification failure, a hematoma, and 4 obturator nerve reflex events, despite the block, were observed and these patients were subjected to general anesthesia with succinylcholine. Fifty-six patients (32 patients initially had general anesthesia and 24 converted from epidural to general anesthesia) were all given succinylcholine prior to resection. CONCLUSION: Due to its mechanism of action, succinylcholine is completely effective and represents a simple alternative to obturator nerve block. No contraction was observed in any patient given succinylcholine.

Administration of local anesthetic through the epidural needle before catheter insertion improves the quality of anesthesia and reduces catheter-related complications.

Epidural catheter placement offers flexibility in block management. However, during epidural catheter insertion, complications such as paresthesia and venous and subarachnoid cannulation may occur, and suboptimal catheter placement can affect the quality of anesthesia. We performed this prospective, randomized, double-blind study to assess the effect of a single-injection dose of local anesthetic (20 mL of 2% lidocaine) through the epidural needle as a priming solution into the epidural space before catheter insertion. We randomized 240 patients into 2 equal groups and measured the quality of anesthesia and the incidence of complications. In the needle group (n = 100), catheters were inserted after injection of a full dose of local anesthetic through the needle. In the catheter group (n = 98), the catheters were inserted immediately after identification of the epidural space. Local anesthetic was then injected via the catheter. We noted the occurrence of paresthesia, inability to advance the catheter, or IV or subarachnoid catheter placement. Sensory and motor block were assessed 20 min after the injection of local anesthetic. Surgery was initiated when adequate sensory loss was confirmed. In the catheter group, the incidence of paresthesia during catheter placement was 31.6% compared with 11% in the needle group (P = 0.00038). IV catheterization occurred in 8.2% versus 2% of patients in the catheter and needle groups, respectively (P = 0.048). More patients in the needle group had excellent surgical conditions than the catheter group (89.6% versus 72.9; P < 0.003). We conclude that giving a single-injection dose via the epidural needle before catheter placement improves the quality of epidural anesthesia and reduces catheter-related complications.

Effects of sevoflurane and desflurane in CA1 after incomplete cerebral ischemia in rats.

OBJECTIVE: We compared the postischemic cerebral protective effects of sevoflurane and desflurane in rats with incomplete cerebral ischemia. METHODS: This study was performed in Ataturk University Medical Faculty in Erzurum, Turkey in 2003. All rats were anesthetized with 5% isoflurane, intubated and mechanically ventilated, then given 2% isoflurane in 70% nitrous oxide and 30% O2. The femoral artery was cannulated. Five minutes before ischemia, and at the end of ischemia, arterial blood was taken for plasma glucose, hematocrit and blood gas analysis. Hypotension was induced by hemorrhage, and then both common carotid arteries were clamped for 10 minutes. In the control group, the arteries were then unclamped and the rats were extubated. In the other 2 groups, isoflurane was discontinued after carotid artery unclamping, and either 2% sevoflurane or 6% desflurane in 70% nitrous oxide and 30% O2 was given for 30 minutes, after which the rats were extubated. Five days later, they were sacrificed, and histological scores in CA1 were graded on a scale 0-3. RESULTS: Histopathological outcome in sevoflurane and desflurane group was not different, but there were differences between sevoflurane and control (p<0.05), and desflurane and control (p<0.01). CONCLUSION: These data indicate that sevoflurane and desflurane have cerebral protective effects when given after ischemia.

Disappearance of phantom limb pain during cauda equina compression by spinal meningioma and gradual reactivation after decompression.

UNLABELLED: We describe a 65-yr-old woman, whose right lower limb had been amputated at the mid-femoral level because of complicated femur fracture sustained at the age of 5 yr. After amputation, she experienced phantom limb pain (PLP), which gradually decreased in intensity but persisted for 60 yr. At this point the pain diminished progressively, in parallel with the evolution of cauda equina compression caused by an intraspinal tumor. The PLP gradually reappeared over 3 mo after surgical removal of the tumor. IMPLICATIONS: We present a case in which phantom limb pain (PLP) in an amputated leg disappeared during cauda equina compression by meningioma and reactivated after surgical decompression. This case suggests that complete compression or blockade of nerves, a nerve plexus, the cauda equina, or the medullary cord may result in suppression of PLP, and decompression of or recovery from the block may cause reactivation.