Acute Carpal Tunnel Syndrome and Median Nerve Neurapraxia: A Review.

Prompt diagnosis and treatment of acute injury to the median nerve after wrist trauma are paramount to a successful outcome. Neuropathy can occur primarily at the time of injury, secondary to unreduced fracture fragments or callus, or from prolonged immobilization in palmar flexion. Acute carpal tunnel syndrome is a surgical emergency that requires decompression. Progressively worsening pain and sensory disturbances in the median nerve distribution are findings that will distinguish an acute carpal tunnel syndrome from the less severe median nerve neurapraxia. This article describes the key differences between neurapraxia and acute compartment syndrome and their respective treatment.

Periarticular liposomal bupivacaine mixture injection vs. single-shot interscalene block for postoperative pain in arthroscopic rotator cuff repair: a prospective randomized controlled trial.

BACKGROUND: The pain control efficacy, postoperative opioid requirements, and costs among patients undergoing major shoulder surgery using different perioperative analgesia modalities have been topics of active debate. Several studies have compared periarticular injection (PAI) to interscalene block (ISB) in shoulder arthroplasty, but there is a paucity of data comparing them in arthroscopic rotator cuff repair. METHODS: Patients aged 18-80 years with full-thickness rotator cuff tears and undergoing primary arthroscopic rotator cuff repair at 2 different shoulder centers were screened and subsequently randomized to receive either periarticular injection (PAI) of liposomal bupivacaine mixed with 0.25% bupivacaine (n = 41) or single-shot interscalene nerve block (ISB) (n = 36). Visual analog scale (VAS) pain scores, oral morphine equivalent (OME) use, Single Assessment Numerical Evaluation (SANE) scores, and costs were collected. Differences with P <.05 were considered statistically significant. RESULTS: Day of surgery VAS score and OME usage were significantly reduced with ISB vs. PAI (0.69 vs. 4.65, P < .001, and 18.66 vs. 34.39, P < .001, respectively). There were no significant differences between groups regarding VAS score on postoperative days (PODs) 1-3; however, OME usage on PODs 1 (50.5 vs. 38.8, P = .03) and 2 (48.1 vs. 37.8, P = .04) was significantly more in the ISB group. At POD 3, VAS score (4.13 vs. 3.97, P = .60) and OME use (28.60 vs. 31.16, P = .51) were similar. At 6 and 12 weeks, there were also no significant differences between groups regarding VAS and OME use. There was no difference in SANE score at 12 weeks following surgery between groups and no difference between average 12-week cumulative OME use between groups. The average charge for the PAI was $455, and the average charge for ISB was $745. CONCLUSION: Both ISB and PAI provide acceptable pain control following arthroscopic rotator cuff repair. Patients have less pain on the day of surgery with ISB, but rebound pain is significant after the block wears off, resulting in substantially increased opioid use in the first 2 PODs. However, cumulative opioid use between groups was similar. There were also no significant differences at the end of the 12-week episode of care in any of the other variables studied. The charge per patient for PAI is approximately $300 less than ISB. Thus, PAI may offer surgeons and patients an effective postoperative analgesic modality as an alternative to ISB.

Postoperative Analgesia in Patients Undergoing Primary or Revision Knee Arthroplasty with Adductor Canal Block.

BACKGROUND: Multimodal analgesia featuring peripheral nerve blocks decreases postoperative pain for patients undergoing primary total knee arthroplasty (TKA). Many anesthesiologists and surgeons advocate for the use of adductor canal blocks (ACBs) for analgesia, which result in less weakness compared to femoral nerve blocks. Few data exist to guide analgesic management in total knee revision (TKR), considered to be more painful than primary TKA. We hypothesized that TKR patients with a continuous ACB would use more opioids than primary TKA patients who received the same analgesic regimen. METHODS: A retrospective study of 58 TKA and TKR patients who received ACBs in a multimodal protocol was conducted from 1/2014 to 3/2016. Exclusion criteria included patients who took ≥ 20 mg of morphine daily preoperatively. The primary outcome was 48-hour opioid consumption. Secondary outcomes included pain ratings, catheter boluses, and catheter infusion rate changes over 48 hours. RESULTS: For the primary outcome of 48-hour opioid consumption, there was no significant difference between groups. Postoperative pain ratings were not significantly different during the overall 48-hour time period. There were also no significant differences in catheter boluses and infusion rate changes. Least squares regression analysis revealed a positive correlation between number of previous knee surgeries and postoperative pain level. CONCLUSIONS: Patients who underwent TKR with continuous ACB experienced a similar postoperative analgesic course as primary TKA patients. Within the TKR cohort, the number of previous revisions was positively associated with pain level. Larger prospective studies with TKR are needed to confirm these findings.

Cardiac surgical delivery of the sarcoplasmic reticulum calcium ATPase rescues myocytes in ischemic heart failure.

BACKGROUND: The sarcoplasmic reticulum calcium ATPase (SERCA2a) is an important molecular regulator of contractile dysfunction in heart failure. Gene transfer of SERCA2a mediated by molecular cardiac surgery with recirculating delivery (MCARD) is a novel and clinically translatable strategy. METHODS: Ischemic heart failure was induced by ligation of OM1 and OM2 in 14 sheep. Seven sheep underwent MCARD-mediated AAV1-SERCA2a delivery 4 weeks after myocardial infarction, and seven sheep served as untreated controls. Magnetic resonance imaging-based mechanoenergetic studies were performed at baseline, 3 weeks, and 12 weeks after infarction. Myocyte apoptosis was quantified by Tdt-mediated nick-end labeling assay. Myocyte cross-sectional area and caspase-8 and caspase-9 activity was measured with imaging software, specific fluorogenic peptides, and immunohistochemistry. RESULTS: MCARD-mediated AAV1-SERCA2a gene delivery resulted in robust cardiac-specific SERCA2a expression and stable improvements in global and regional contractility. There were significantly higher stroke volume index, left ventricular fractional thickening, and ejection fraction at 12 weeks in the MCARD group than in the control group (30 ± 3 vs 21 ± 2 mL/m(2); 12% ± 5% vs 3% ± 3%; and 43 ± 4 vs 32 ± 4, respectively, all p < 0.05). Apoptotic myocytes were observed more frequently in the control group than in the MCARD-SERCA2a group (0.57.2 ± 0.16 AU vs 0.32.4 ± 0.08 AU, p < 0.05). MCARD-SERCA2a also resulted in decreased caspase-8 and caspase-9 expression and decreased myocyte area in the border zone of transgenic sheep compared with control sheep (14.6% ± 1.2% vs 2.9% ± 0.7%; 18.2% ± 1.9% vs 8.6% ± 1.4%; and 102.1 ± 3.8 µm(2) vs 88.1 ± 3.6 µm(2), all p < 0.05). CONCLUSIONS: MCARD-mediated SERCA2a delivery results in robust cardiac specific gene expression, improved contractility, and a decrease in both myocyte apoptosis and myocyte hypertrophy.