Cervical Nerve Blocks

This divides into pre- and postauricular branches to supply the greater part of the ear. The landmark for this block is the tip of the mastoid process. Infiltration of 2 mL of local anesthetic in an anterior and 2 ml in a posterior direction from this landmark is sufficient to block both branches. Greater and Lesser Occipital Nerve Blocks. Occipital nerve block is indicated for posterior scalp anesthesia or relief of headache associated with muscular tension or...

B

Pentation Mitch

Figure 18-18 A and B, Disposable CSE needle sets. Figure 18-18 A and B, Disposable CSE needle sets. Figure 18-19 The Tuohy needle modified to reduce the risk of catheter penetration through the dura and damage to the bevel by B. Braun, Melsungen AG, Sweden. Figure 18-19 The Tuohy needle modified to reduce the risk of catheter penetration through the dura and damage to the bevel by B. Braun, Melsungen AG, Sweden. lead to a more extensive spread because of changes in volume and circulation of...

Table 351 Main Diagnostic Criteria For Cervicogenic Headache

Facet Pain Patterns

Symptoms and signs of neck involvement Pain precipitated by mechanical pressure to the ipsilateral upper posterior neck region or by awkward head positioning Ipsilateral neck shoulder arm pain Reduced range of motion in the cervical spine Pain characteristics Nonclustering pain episodes of varying duration (or fluctuating, continuous pain) Moderate, usually nonthrobbing pain, starting in the neck and spreading forward Other important criteria Anesthetic blockade of the greater occipital nerve...

References

Bonica J, Loeser JD History of pain concepts and therapies. In Bonica J (ed) Bonica's Management of Pain. New York, Lippincott Williams & Wilkins, 2001, pp 4-7. 2. Galen C De Usu Portium. Ithaca, NY, Cornell University Press, 1968. 3. Fields HL, Basbaum AI Central nervous system mechanisms of pain modulation. In Wall PD, Melzack R (eds) Textbook of Pain, 4th ed. New York, Churchill Livingstone, 2000, pp 309-323. 4. Mersky H, Bogduk M Classification of chronic pain Definitions of pain terms,...

Posttraumatic Stress Disorder

Post-traumatic stress disorder is a state characterized by high levels of anxiety after a traumatic incident. Panic attacks, phobic reactions related to stimuli involving the original traumatic event, and pain symptoms predominate. Symptoms consistent with PTSD in chronic pain patients are associated with affective distress1 and depression.1 The PCPT has been developed as a screening instrument to aid in early detection of PTSD. Patients who attribute their pain to a specific traumatic event,...

Info

From Auroy Y, Narchi P, Messiah A, et al. Serious complications related to regional anesthesia. Results of a prospective survey in France. Anesthesiology 87 479486,1997. Reproduced with permission. * Number of cases, (rate per 10,000) and (95 confidence interval). ' P < 0.05 epidural vs. spinal anesthesia. * Number of cases, (rate per 10,000) and (95 confidence interval). ' P < 0.05 epidural vs. spinal anesthesia. Pleym and Spigset concluded that the causal relationship between the...

Lower Extremity Blocks

Peripheral nerve blocks are employed to provide analgesia in patients with lower extremity trauma. Blockade of the femoral nerve is performed to provide pain relief and abolish muscle spasm in patients with fracture of the shaft of the femur. A lumbar plexus block or a combination of femoral, lateral femoral cutaneous, and obturator nerve blocks can be useful for surgery on the proximal femur and the femoral neck. A combined lumbar plexus block and sciatic nerve block provide anesthesia for...

The Thorax

General surgical procedures of the thorax are now generally restricted to the chest wall. Thus, the general surgeon performs operations for pathologic conditions Figure 24-32 Technique of regional anesthesia for thyroid surgery. Note that bilateral deep cervical plexus block is essential to anesthetize the structures that will be stretched by retractors. In addition, skin infiltration in the area of the incision helps to minimize bleeding. (From Raj P Clinical Practice of Regional Anesthesia....

The Endogenous Opioid System

Opioid receptors are classified as 5, and k receptors ( Table 14-2 ). The classification of the effect of opioid agonists and antagonists on opioid receptors is shown in Table 14-3 . These opioid receptors belong to a superfamily of guanine (G) protein-coupled receptors that constitute 80 of all known receptors, including muscarinic, adrenergic, y-aminobutyric acid, and somatostatin receptors. or morphine-preferring receptors are principally responsible for supraspinal and spinal analgesia....

Cancer Treatmentrelated Pain

Up to a third of women develop pain as a result of treatment of breast cancer.173 The pain is often described as a general burning and aching sensation referred to the axilla, the medial upper arm, the chest, or all of these areas. There may be paroxysmal episodes of shooting and lancinating pain. In addition, some women report phantom breast pain, mainly in the nipple. The pain may be exacerbated with arm movement, leading to a frozen shoulder as the patient attempts to

Outcome Studies Of Interpleural Analgesia In Cancer Pain

Interpleural analgesia may also be a useful addition to systemic analgesic medications in the treatment of moderate or severe cancer pain. There have been published reports of successful results from interpleural analgesic therapy for both nonmetastatic and metastatic cancers of the gastrointestinal tract, including the pancreas, kidney, breast, and lung as well as lymphoma, sarcoma, histiocytoma, and myeloma.11 1113 113 11531 11511 11551 11561 This evidence describing the use of interpleural...

Upper Extremity Blocks

Studies of perineural steroid injection, generally combined with local anesthetic, for the treatment of carpal tunnel syndrome were examined by Abram.143 Initial efficacy was found in multiple studies to range from 77 to 92 . However, many studies that followed patients for at least 1 year found continued benefit in only 13 to 22 . A prospective, randomized, double-blinded, placebo-controlled study measuring the short-term efficacy of steroid versus saline injection into the carpal tunnel was...

Epidural Steroid Injections

Epidural steroid injections (ESIs) have been used for low back and radicular pain for almost 50 years.13 Today they rank as one of the most common interventional procedures performed by pain management specialists. ESIs are primarily indicated as part of a nonoperative approach to the treatment of spinal and radicular pain. Pages first described his technique for accessing the epidural space via a paramedian approach in 1921s The technique involved the use of loss of resistance to the needle as...

Adrenal And Renal Hormones And Catecholamines

In studies using rather large volumes of bupivacaine (0.5 ) and a well-described neural blockade, the intra- and postoperative increases in plasma cortisol, aldosterone, and renin, as well as catecholamines, have been inhibited. Although no systematic studies are available, rather large doses of bupivacaine seem to be necessary to achieve eradication of these stress parameters. -Lipotropic - Endorphin t ACTH4 GHI AVPJ-TSHt LH FSH* Prolactin t Testes ovaries Testosterone Estradiol...

Allergic Reactions

Allergic reactions to local anesthetics may occur. Reputedly, allergic reactions are more likely to occur with ester-linked local anesthetics than with amide-linked ones. Methylparaben, a preservative sometimes added to local anesthetic solutions, may cause allergic-type reactions. Cutaneous and respiratory reactions are the most common indicators of anaphylaxis. There is little information about whether or not toxic responses to local anesthetics are age dependent. Preliminary data from...

Amide Local Anesthetics

In contrast to the ester-linked drugs, the amide-linked local anesthetics must be transported by the circulation to the liver before biotransformation can take place. The two major factors controlling the clearance of amide-linked local anesthetics by the liver are (1) hepatic blood flow (delivery of the drug to the liver) and (2) hepatic function (drug extraction by the liver). Factors that decrease hepatic blood flow or hepatic drug extraction result in an increased elimination half-life. For...

An American Twist

Although Europe was the birthplace of spinal anesthesia, two pioneering surgeons, F. Dudley Tait and Guido E. Caglieri, administered the first spinal anesthetic in America on October 26, 1899. Tait and Caglieri studied 7 cadavers, 11 patients, and an unknown number of cats, dogs, rabbits, guinea pigs, and horses in their efforts to further understand how lumbar puncture could benefit patients. Although they never clearly stated their reasoning, Tait and Caglieri were apparently trying to...

Anatomic And Physiologic Considerations

First, there are some differences in the anatomy of spinal cord meninges between a neonate and an adult. The tip of the spinal cord is at L3 at birth and L1 to L2 at 1 year. In the same way, the meninges are at S3 at birth and S4 to S5 at 1 year ( Fig. 21-1 ). In addition, infants and children who weigh less than 15 kg have a relatively high volume of cerebrospinal fluid (CSF) 4 ml kg of body weight compared with adult values of 2 ml kg body weight. The contents of the epidural space in infants...

Anatomy

The subarachnoid space extends to the level of S, and the enclosed spinal cord usually extends down to L1. A needle inserted below L should not encounter the substance of the spinal cord, but it might encounter the cauda equina. In the midline, the spinal needle traverses the skin, the supraspinous ligament, the interspinous ligament, the ligamentum flavum, and the epidural Figure 18-5 Sagittal section of the lumbar region shows the spine's interspinous and supraspinous ligaments and ligamenta...

Anesthesia

CHAN To achieve consistently successful outcomes with regional anesthesia, practitioners must have adequate knowledge and experience. Increasing pressure on both trainers and trainees, combined with the complexity of modern general anesthetic agents, has caused anesthetic trainees to become less familiar and thus less confident in the practice of many regional anesthetic techniques. Often, it is easier to give a general anesthetic, especially when faced with...

Assessment Of Chronic Pain

In the early 1970s, chronic pain began to gain special attention as a discrete clinical syndrome that required diagnosis and treatment in special clinics involving interdisciplinary teams. The need for robust measurement tools and techniques led investigators to research and develop reliable and valid instruments for assessing chronic pain. For instance, an algometer was one of the many devices invented to measure chronic pain by comparing it with acute pain induced by a brief electric current...

Behavioral Medicine

Incorporation of cognitive behavior therapy in the medical care of chronic low back pain patients in a controlled, randomized study caused patients to experience less pain, better control, more pleasure, less avoidance, and less disability. Relaxation and imagery were primary components of therapy.1 Although some contend that cognitive behavior programs help regardless of whether the patients are treated individually or as a group, others claim that inpatient or full-time intensive treatments...

Bladder Surgery

Cystoscopic procedures done for diagnosis or surgical manipulation are relatively minor procedures and may even be performed on an outpatient basis. Spinal, lumbar epidural, caudal, or transsacral block provide entirely satisfactory analgesia. Urethral instrumentation, especially in females, can be performed with topical anesthesia with 2 lidocaine jelly without much discomfort to the patient. Conduction anesthesia to achieve a level of T9 is equally satisfactory, and the choice of drug depends...

Blood Supply Of Nerve Roots And Dorsal Root Ganglia

In the cervical spinal cord, the anterior and posterior radicular arteries supply the nerve roots. These radicular arteries are classified further as either proximal or distal. The proximal radicular artery is a branch from the anterior or posterior spinal artery, while the distal radicular artery is a direct branch of the vertebral artery and enters the dural root pouch on the anterior surface of its respective root.19 115 A ganglionic artery supplies the cervical DRG, which is often a direct...

Brachial Plexus And Branches

Fractures of the upper extremity, especially at the elbow and wrist, are common injuries during the summer months when children are outside playing on jungle gyms and riding skateboards. These patients are often brought for treatment in the late afternoon or early evening, having eaten just before the traumatic event. Surgery focuses on reduction and realignment procedures with hardware insertion and casting. Use of a sedative may complicate the anesthetic considerations of a full stomach. In...

Brachial Plexus Block

In 1884, less than a year after the discovery of the anesthetic properties of cocaine, William Halsted performed the first regional blockade of the brachial plexus. His technique involved surgical exposure of the plexus in the neck with subsequent intraneural blocking of individual nerves.143 Effectively providing complete anesthesia to the upper extremity, the procedure itself was, at times, nearly as extensive as the surgery for which it was being provided. Unfortunately, an addiction to...

Branko M Weiss Eli Alon

Outcome and Seven Pillars of Quality Avedis Donabedian 13 asserted that the seven pillars, or attributes, that define quality in healthcare13 are (1) efficacy (ability to bring improvements) (2) effectiveness (degree to which the care could attain the level of improvement that studies of efficacy have established as attainable in the clinical practice) (3) efficiency (if two approaches are equally efficacious or effective, the less costly one is the more efficient) (4) optimality (relationship...

Breech Presentation

Neuraxial labor analgesia for planned breech vaginal delivery offers several benefits, including inhibition of early pushing, relaxation of the pelvic floor and perineum, and the option of extending anesthesia for emergency cesarean delivery. Early pushing may increase the risk of umbilical cord prolapse and delivery of a lower extremity before full cervical dilation. A relaxed pelvic floor facilitates delivery of the after-coming head. The challenge to the anesthesiologist is to provide enough...

Buttock And Low Back Pain

It is more difficult to treat pain that is axial (i.e., pain perceived in the middle to lower back) and buttock pain.'82 82 m aa dm m Dual-lead stimulation, again with either two catheter-type electrodes or one plate-type electrode with columns of contacts, can be effective. The rationale is that stimulation applied by both columns at the same time can provide denser and deeper stimulation to the axial fibers that are deep within the posterior midline aspect of the spinal cord. Some adjustment...

Cardiac Surgery

The use of epidural anesthesia for cardiac surgery is limited because of the unstable volume status of these patients. However, the possible use of epidural and subarachnoid narcotics for postoperative pain management has recently been explored.1112 There has been a concern in cardiac surgery and other forms of vascular surgery that the use of heparin precludes the placement of an epidural catheter owing to the potential for bleeding and hematoma formation in the epidural space. In vascular...

Cardiovascular Disease

The diagnosis and treatment of congenital heart disease has improved markedly over the past several decades, leading to an increased number of pregnant women with congenital heart disease. The sympathectomy associated with neuraxial techniques acutely decreases systemic vascular resistance and myocardial preload. This sudden change may not be well tolerated in women with stenotic valvular lesions, asymmetrical septal hypertrophy, or right-to-left shunts. In contrast, patients with left-to-right...

Caudal Block

Caudal Anesthesia Landmarks

This is the most useful pediatric block, because it is widely applicable and technically simple. Indeed, caudal anesthesia is very easy to administer to a child rather than an adult in whom the caudal block is often difficult and occasionally impossible. The caudal block can provide analgesia for surgery up to and including the umbilicus. This technique can be used successfully in neonatal rectal surgery.123 The anesthetic agent is injected through the sacral hiatus, which is formed by failure...

Cckb

CCK-B, cholecystokinin-B NMDA, N-methyl-D-aspartate. clinical use of opioids in the epidural or subarachnoid space in order to ameliorate acute and chronic pain. Analgesia that is seen after epidural or spinal administration of opioids, in contrast to regional anesthesia with local anesthetics, is not associated with sympathetic nervous system denervation, is dose related, and is specific for visceral rather than somatic pain. The main objective in using spinal opioids is to obtain a reduction...

Central Nervous System

After absorption, local anesthetics may cause stimulation of the CNS, producing restlessness and tremor that may proceed to clonic convulsions. In general, the more potent the anesthetic, the more readily convulsions may be produced. Alterations of CNS activity are thus predictable from the local anesthetic agent in question and the blood concentration achieved. Central stimulation is followed by depression death is usually caused by respiratory failure. The apparent stimulation and subsequent...

Central Neuraxial Techniques For Cesarean Delivery

The literature suggests that spinal, epidural, or combined spinal-epidural techniques can be used effectively for cesarean delivery. When compared to regional techniques, the literature indicates that general anesthetics can be administered with shorter induction-to-delivery times.1341 The ASA Task Force concluded that the literature is insufficient to examine the comparative merits of various regional anesthetic techniques, but fewer complications and improved maternal satisfaction result from...

Cervical Facet Joints

The anatomy of the cervical facet joints is considerably different from that of the lumbar region. Although they are still composed of the superior articular process of the vertebra below and the inferior articular process of the vertebra above, their capsular anatomy, orientation, and biomechanics differ significantly from their lumbar counterparts. The configuration of the joints also depends on the cervical level that is being addressed, as upper cervical segments differ substantially from...

Cervical Nerve Roots

Selective blockade of the C3 to C8 nerve roots is performed in the same manner. The patient is placed in the supine position with the head in the neutral position. After obtaining an anteroposterior (AP) fluoroscopic view of the cervical spine, the C-arm is positioned obliquely until the neuroforamina are clearly visualized. The proper angle causes the ipsilateral vertebral laminae to appear as a string of beads. A skin wheal is raised with local anesthetic just posterior to the posterior...

Cervical Spine

In the cervical spine, the posterior compartment, comprised of facet joints and intrinsic back muscles (semispinalis capitis, semispinalis cervicis, multifidus, and interspinalis), is innervated by the cervical posterior rami. The spinal nerve divides into anterior and posterior rami as it exits the foramen. After a short trajectoryof 2 to 5 mm, the posterior ramus divides into a medial and a lateral branch. In the cervical region, these branches are separated by the semispinalis capitis...

Clinical Research

Introduction and Historical Perspective It is the purpose of this chapter to review some of the clinical research in regional anesthesia as it relates to current developments in surgery and pain management. These advances in clinical research are related to the use of drugs, administration techniques, and equipment. Many of these developments are far from recent, and it is important to place them in historical perspective to understand the development of regional anesthesia. The origins of...

Radiographic Imaging in Regional Anesthesia

Radiographic Image Adequacy

Use of radiography in regional anesthesia and pain management has grown more important as the field has developed. Radiographic diagnostic tests such as plain films, computed tomography (CT), magnetic resonance imaging (MRI), and bone scans are frequently obtained to find simple fractures or degenerative joints, disc bulges, herniations, and spinal cord or nerve impingement. During the performance of many procedures, fluoroscopy or CT is used to place the nerve blocks with precision. Because of...

Vertebroplasty

Vertebroplasty is the percutaneous augmentation of a vertebral body using polymethylmethacrylate. Polymethylmethacrylate (PMMA) was first introduced in 1970 by Charnley for orthopedic use in total hip replacements.13 In 1984, Deramond and associates113 in France performed percutaneous bone augmentation using PMMA. They placed the PMMA in the cervical vertebra of a 50-year-old woman who had a C2 vertebral hemangioma with a long-term complaint of neck pain. The patient reported complete pain...

Chloroprocaine

2-Chloroprocaine (Nesacaine), an ester local anesthetic introduced in 1952, is a chlorinated derivative of procaine (see Fig. 13-12 ). Its major assets are its rapid onset and short duration of action and its reduced acute toxicity due to its rapid metabolism (plasma half-life approximately 25 s). Enthusiasm for its use has been tempered by reports of prolonged sensory and motor block after epidural or subarachnoid administration of large doses. Figure 13-12 Local anesthetic chemical structures...

Christopher J Jankowski

Complications from neuraxial anesthesia have been recognized since August Bier reported the first spinal anesthetic over 100 years ago.12 Fortunately, serious complications of neuraxial anesthesia remain rare but can be devastating when they occur. As morbidity and mortality from anesthesia and surgery continue to decline, the relative importance of these problems increases. Safe, effective practice of neuraxial anesthesia requires a detailed knowledge of the potential complications, their...

Chronic Pain After Trauma

Pain persisting beyond the normal recovery period, and often greatly exceeding what might be anticipated relative to the residual pathology, can be considered chronic post-traumatic pain. Although it is widely assumed that psychological factors become increasingly important as acute pain becomes chronic, it is perhaps less well appreciated that a number of pathophysiologic changes also occur in both central and peripheral pain pathways. Consequently, the response of patients with chronic pain...

Clonidine

Epidural clonidine, through a spinal site of action, provides significant and segmental labor analgesia, sedation, and maternal blood pressure and heart rate decrease.1 The appropriate dose was set at 75 g. Clonidine effect was found to prolong pain relief for (mean) 56 to 122 minutes and duration of labor for (mean) 113 minutes, compared with local anesthetic alone.14681 1423 Fetal heart rates were normal and high Apgar scores were found with high plasma umbilical cord clonidine...

Cocaine

Cocaine occurs in abundance in the leaves of the coca shrub and is an ester of benzoic acid and methylecgonine. Ecgonine is an amino alcohol base closely related to tropine, the amino alcohol in atropine. It has the same fundamental structure as the synthetic local anesthetics. Pharmacologic Actions and Preparations The clinically desired actions of cocaine are the blockade of nerve impulses as a consequence of its local anesthetic properties, and local vasoconstriction secondary to inhibition...

Combined Spinalepidural Analgesia

Combined spinal-epidural (CSE) analgesia for labor was introduced into the obstetric anesthesiologist's armamentarium in the early 1990s after Leighton and colleagues demonstrated that intrathecal fentanyl rapidly provided profound analgesia. The technique combines the advantages of spinal and epidural analgesia. Opioid alone, or opioid in combination with a local anesthetic, is injected intrathecally to initiate neuraxial analgesia. Maintenance analgesia is provided via the epidural catheter....

Combined Spinalepidural Anesthesia

CSE anesthesia can be used several ways for cesarean delivery anesthesia. CSE anesthesia combines the advantages of spinal anesthesia (rapid onset of a dense block) with those of epidural anesthesia (ability to prolong the block). Anesthesia may be initiated with a standard spinal dose followed by placement of the epidural catheter.113 The catheter is injected if the block needs to be prolonged. Alternatively, a low spinal dose can be injected, with the remaining initiation dose injected...

Concepts Of Spinal Morphology And Implications For Therapy

The difficulty in treating chronic spinal pain necessitates the study of the anatomy and pathoanatomy of the components of the vertebral column commonly involved in the genesis and perpetuation of chronic spinal pain. The backbone possesses numerous potential pain generators. In fact, every structure in the spine that is innervated can be a potential source of pain. The internal venous plexus and the ligamentum flavum are not known to be innervated. Some areas identified by neuroanatomic...

Continuous Spinal Anesthesia

Seven years after Bier's landmark work on the administration of cocaine via lumbar puncture, Henry Percy Dean, a British surgeon, introduced a modification of the technique called continuous spinal anesthesia.123 Unfortunately, many of his colleagues who attempted the procedure encountered difficulties such as needle trauma and breakage. Therefore, the technique fell into disfavor, as can be evidenced by the lack of citations referring to continuous spinal anesthesia in the English language...

Contraindications

Circumstances that make spinal anesthesia inadvisable include conditions that may potentiate bleeding into Figure 18-11 A, Anterior view with dermatomal distribution of the body wall. B, Posterior view with dermatomal distribution of the body wall. Figure 18-11 A, Anterior view with dermatomal distribution of the body wall. B, Posterior view with dermatomal distribution of the body wall. the central nervous system (blood dyscrasia, coagulopathies), which may cause infection of the meninges of...

Cosmetic Indications

Essential hyperhidrosis and excessive facial blushing can be so disabling to some individuals that they seek surgical redress in the form of sympathectomy. These two symptoms can be considered as physical manifestations of social phobic reactions, which are psychiatric conditions with criteria contained in the Diagnostic and Statistic Manual. It has even been considered ethically sound to perform endoscopic transthoracic sympathectomy for selected patients with social phobia resistant to...

Countries

About three quarters of the countries of the world fall into the category of developing countries, and four fifths of the world's population lives in them. How does one categorize these countries What is the politically correct definition of a developing country The concept of the Third World emerged after World War II as a category to identify political neutrality in the context of the Cold War, with the distinction originally based on ideologic commitment rather than conditions of economic...

D

Individual, group, and family psychotherapy 2. Cognitive-behavioral therapies 3. Biofeedback and relaxation techniques IV. Specific types of painful conditions to be included in the fellow's educational program A. Pain associated with cancer, including issues of death and dying, palliative care, and hospice care B. Postoperative and post-trauma pain C. Pain associated with nervous system injuries D. Pain associated with chronic disease V. Regional pain syndrome to be included in the fellow's...

Definition Of Terms

The following terms are defined briefly in this section a more complete description of the characteristics of each type of facility appears in subsequent portions of this chapter. 1. Pain Treatment Facility. This generic term is used to describe all forms of pain treatment facilities without regard to personnel involved or types of patients served. Pain unit is a synonym for pain treatment facility. 2. Multidisciplinary Pain Center. This organization of healthcare professionals and basic...

Desirable Characteristics Of A Multidisciplinary Pain Center

A multidisciplinary pain center (MPC) should have on its staff a variety of healthcare providers capable of assessing and treating physical, psychosocial, medical, vocational, and social aspects of chronic pain. These therapists work with occupational therapists, vocational counselors, social workers, and any other type of healthcare professional who can make a contribution to patient diagnosis or treatment. 2. At least three medical specialties should be represented on the staff of a...

Development Of Other Local Anesthetics

It was only natural that discoveries in organic chemistry, both analytic and synthetic, should have led to efforts to find preparations with good anesthetic properties and without the drawbacks of cocaine. Besides its highly acute toxicity and the risk of addiction (which came to play a greater role as time went by), cocaine is easily decomposed when the solution is sterilized. It is also expensive. As emphasized by Willstatter, the vegetable bases, such as cocaine, are often so complex that...

Discussion

The limitation of this survey is that it reflects only the practice of regional anesthesia in the institutions that responded. The sample size was small, mainly because of the difficulty in obtaining the names and addresses of hospitals in different countries. There is no Asian directory or list of hospitals available that one could choose from. The Asia Oceanic Society of Regional Anesthesia mailing list was chosen because it was the most up-to-date list available, but many of the members had...

Dorsal Root Ganglion

Location of the DRG is of prime importance when a radiofrequency procedure of the DRG is considered. Considerable anatomic variance exists, as one would expect. Several anatomic studies have been performed to elucidate the position of the DRG. The ganglia of C1 and C2 are situated on the arches of the vertebrae over which the nerves pass. In a study involving 15 cadavers, Lu and Ebraheim13 noted that the C2 nerve root and ganglion exit from the spinal cord and travel out the foramen following...

Drug Choice

Studies with sheep found that certain drugs, particularly lipophilic morphine-type drugs, encounter difficulties in the process of diffusing through the cerebrospinal fluid (CSF) pathways to reach distant receptors. Thus, the choice of opioid for infusion must account for the location of receptors. Using drugs like hydromorphone, morphine, methadone, naloxone, and sucrose, as a control, Payne and coworkers tested the spread of specific opioids in CSF. Approximately 90 minutes after...

Efficacy Of Procedure

One of the biggest challenges to the anesthesiologist performing a regional procedure is to be successful in anesthetizing the patient, in the right area and with enough spread to cover the whole surgical procedure. The monitoring of efficacy of the block starts with the evaluation of the quality, depth, and extension of the blockade. This means that different surgical steps and the patient's responses to them must be monitored. Sometimes, the blockade may cover a sufficient area, but the...

Epidural Anesthesia

Epidural anesthesia is frequently used for parturients with indwelling catheters placed for labor analgesia. It may also be the regional anesthetic technique of choice in parturients for whom the slow onset of sympathetic blockade may be beneficial (e.g., patients with cardiac disease). Additionally, epidural anesthesia results in a less dense motor block than spinal anesthesia. This type of block may be advantageous in patients with pulmonary disease who rely on abdominal and intercostal...

Epidural Block

Epidural block is an effective technique for intra- and postoperative pain relief. However, general anesthesia is almost always required if the epidural and surgical procedures are to be performed under satisfactory conditions. The greatest advantage of epidural block is the long-term analgesia after major surgery of the chest and abdomen and some orthopedic procedures.111 13 13 In these cases, a combination of light general anesthesia with endotracheal intubation and epidural anesthesia is...

Eudynia And Maldynia

To discuss the topic of chronic pain (maldynia), one must understand acute pain (eudynia). The International Association for the Study of Pain (IASP) defines acute pain as an unpleasant sensory and emotional experience associated with actual and potential tissue damage and also describes pain in terms of tissue damage.12 The latter type of pain has biologic usefulness in that the experience locates body areas that are being attacked by external or internal noxious inputs, while activating fight...

Fentanyl

Fentanyl is an opioid analgesic that preferentially binds to receptors, which are found widely distributed throughout the brain and spinal cord. Like sufentanil, it is lipophilic and has a fast onset of action, about 4 to 5 minutes with a peak effect of approximately 20 minutes when given epidurally Its analgesic effect is mostly segmental because of its lipophilicity and easy diffusability. Fentanyl has low CSF spread and is equipotent when given either epidurally or intravenously.11 Fentanyl...

Fibrinolyticthrombolytic Drugs And Neuraxial Block

The physiologic state induced by the use of fibrinolytic and thrombolytic agents represents a unique problem in performing regional anesthesia. With the advances in fibrinolytic thrombolytic therapy, we may see increased use of these drugs in the perioperative period, which will require further increases in vigilance. We believe 1. Patients receiving concurrent heparin with fibrinolytic and thrombolytic drugs are at high risk of adverse neuraxial bleeding during spinal or epidural anesthesia....

General

Spinal cord stimulation has been found to be effective for neuropathic pain in general and is less often used for either visceral or somatic pain. The neuropathic pain entities include sympathetic-dependent pain thus, spinal cord stimulation is often considered as a first-line treatment for intractable pain caused by nerve damage resulting from repeated back operations, epidural scarring, or arachnoiditis. It is also useful for peripheral nerve injury syndromes such as stump pain, phantom pain,...

Head And Neck

Pain related to a malignant neoplasm of the head and neck poses one of the most challenging pain management problems because of the overlapping sensory innervation of the area. Most of the pain can be managed with medical regimens however, neural blockade can be a very effective addition. 194 1951 Sensory innervation of the head and neck arises from cranial nerves V, VTT, TX, and X, and dorsal roots of the second, third, and fourth cervical nerves. Sympathetic innervation derives from the T1...

Head And Neck Surgery

Common general surgical operations around the head and neck include thyroid and parathyroid surgery, operations on the lymphatic system, and surgery for lesions of the scalp and neck, including drainage of abscesses and removal of cutaneous and subcutaneous tumors. The scalp is supplied anteriorly by branches of the ophthalmic section of the trigeminal nerve the supraorbital nerve, the supratrochlea nerve, and the auriculotemporal nerve. Posteriorly, the scalp is supplied by branches of the...

Hemodynamic Changes And Prevention Of Arterial Hypotension

The cardiovascular system undergoes a complex set of changes throughout pregnancy to provide ideal conditions for fetal growth, labor, and delivery, and to cope with maternal postpartum adaptation. Tndividual cardiovascular characteristics may range widely, and the adaptation should not be seen as uniform or (quantitatively, qualitatively, or chronologically) sufficient. Healthy and less healthy parturients are exposed to different degrees and qualities of cardiovascular adaptation, to the...

History

The long history of spinal anesthesia and the safety of local anesthetics are aptly documented by the classic studies of Dripps and Vandam, 143 Phillips and coworkers,143 and, more recently, Horlocker and colleagues.143 The Horlocker study (data collection stopped as of June 1990) reported a frequency of persistent sensory and motor deficits in the range of 0.005 to 0.7 , as had the previous, large-survey studies. None of these reviews encompassed the recent period of time, when serious...

Indication

The ideal indication for decompressive neuroplasty is radiculopathy due to epidural fibrosis and nerve root entrapment. For chemically sensitive discs, failed back surgery syndrome, and associated epidural inflammations, the placement of the catheter in the anterior lateral epidural space has been extremely effective. In spinal stenosis, neuroplasty techniques have been helpful in some situations by decreasing edema and venous congestion, with the expected effect of attenuating the compressive...

Indications

The principal indication for epidural corticosteroid injection is nerve root irritation. This irritation can result from mechanical pressure, inflammation, ischemia, or a combination of these three processes. Nerve root irritation expresses itself as radicular pain and may be associated with neurologic deficits in the distribution of the nerve root. Classically, the patient has sharp, shooting pain that radiates to the leg and below the knee. Patients with upper extremity radiculopathy may not...

Intraperitoneal Local Anesthetics

Eds And Local Anesthesia

In keeping with the idea that pain should be treated at the peripheral site, efforts have been made to elucidate the effect of intraperitoneal local anesthetics, but the results have been fairly negative with regard to both pain relief and modification of the surgical stress response.13 Figure 23-2 Neural blockade techniques that may influence the response to surgical injury. (From Kehlet H Endocrine-metabolic effects. In Raj PP ed Clinical Practice of Regional Anesthesia. New York, Churchill...

Intrathecal Alcohol

The patient is placed in the lateral position with the affected extremity upward. The patient should be rolled forward into a 45-degree oblique position. This maintains the posterior roots in the uppermost position. A spinal needle should then be placed into the intrathecal space at the vertebral interspace of the dermatome to be blocked. A volume of up to 0.5 mL of 100 alcohol may be administered at a slow rate. It is recommended that a tuberculin syringe be used and that increments of 0.1 mL...

Intrathecal Phenol

The patient is placed in the lateral position, with the affected extremity downward. The patient should be rolled backward into a 45-degree oblique position. This maintains the posterior roots in the lowermost position. For upper thoracic pain, a spinal needle is placed into the intrathecal space at the vertebral interspace of the dermatome to be blocked. For mid to lower thoracic or abdominal pain, a spinal needle is placed into the intrathecal space one or two segments above the vertebral...

Intrathecal Pump Delivery Systems

As stated earlier in this chapter, intraspinal drugs can be delivered externally through externalized epidural or intrathecal catheters or delivered internally through implanted pump systems. Because external delivery systems are discussed in another chapter, our discussion in this chapter is focused on implanted drug delivery systems. The first drug delivery system approved for the delivery of intraspinal analgesics was the Infusaid model 400 pump, which is no longer in production. The...

Jackknife Position

This position is used mainly for anorectal surgery with a hypobaric solution. Care must be taken with the patient's position during the procedure to avoid pressure points on the pelvis, thighs, or lower legs. The gloved anesthetist prepares the skin of the lumbar area with a bactericidal preparation, wiping off the excess solution. The field is draped with sterile towels. The appropriate interspace is located. Depending on the special anatomic features of the patient, the second, third, or...

James E Heavner

Block of voltage-gated sodium channels by local anesthetics injected near peripheral nerves produces sensory and or motor block. Binding of opioids to opioid receptors, especially receptors, produces analgesia. Inhibition of the enzyme cyclooxygenase (e.g., by aspirin) prevents sensitization of nociceptors. This and other information fundamental to the management of acute and chronic pain is a result of clinical and basic research that has progressively built on prior knowledge. In this...

L2 Communicating Ramus

Anterior Rami T11

Percutaneous facet denervation and percutaneous partial rhizotomy have traditionally been the minimally invasive RF techniques used in the treatment of back pain. Recent advances in knowledge of the innervation of the anterior vertebral compartment have led to the development of performing RF lesions close to the exiting segmental nerves, with the aim of interrupting part of the afferent impulses from the anterior mechanical compartment. Based on anatomic considerations, the following technique...

Lateral Popliteal Sciatic Block

Using anatomic studies performed by Vloka and colleagues193 and Zetlaovi and associates, the patient is asked to slightly flex the knee, which enhances palpation Figure 20-52 Sciatic nerve block Lateral popliteal approach. Figure 20-52 Sciatic nerve block Lateral popliteal approach. of the groove between the vastus lateralis and biceps femoris muscles. After the groove is identified, the leg is straightened. Where the lateral line from the patella intersects the groove is the point of needle...

Leland Lou Raj Sabar Alan D Kaye

Local anesthetics prevent or relieve pain by interrupting nerve conduction. They bind to a specific receptor site within the pore of the Na+ channels in nerves and block ion movement through this pore. In general, their action is restricted to the site of application and rapidly reverses on diffusion from the site of action in the nerve. The chemical and pharmacologic properties of each drug determine its clinical use. Local anesthetics can be administered by a variety of routes, including...

Local Anesthetics For Eye Surgery

Anesthesia of the cornea and conjunctiva can be obtained readily by topical application of local anesthetics. However, most of the local anesthetics described earlier are too irritating for ophthalmologic use. The Figure 13-18 Structurally similar to procaine the difference is that it lacks the terminal diethylamino group. Figure 13-18 Structurally similar to procaine the difference is that it lacks the terminal diethylamino group. Figure 13-19 The most frequently used local anesthetics in...

Local Anesthetics For Skin And Mucous Membranes

Some anesthetics are either too irritating or too ineffective to be applied to the eye. However, they are useful as topical anesthetic agents on the skin, mucous membranes, or both. These preparations are effective in the symptomatic relief of anal and genital pruritus, poison ivy rashes, and numerous other acute and chronic dermatoses. They are sometimes combined with a glucocorticoid or antihistamine and are available in a number of proprietary formulations. Dibucaine (Nupercainal) is a...

Lower Abdominal Intraperitoneal Procedures And Pelvic Surgery

The lower abdomen is innervated by somatic and visceral nerves. The wall is supplied by the 10th to 12th thoracic nerves and the first and second lumbar somatic nerves. All the abdominal viscera, including the gonads, and except the distal colon, are supplied by the celiac plexus. The pelvic viscera and the colon distal to the splenic flexure are supplied by the hypogastric plexus. Pelvic viscera and bones are innervated by the first lumbar to the fifth sacral nerves. Lower abdominal surgery...

Lumbar Facet Pain

Intravertebral Anesthesia

The implications of the lumbar facet joint as the primary and sole source of pain have been debated. In the lumbar region, the prevalence of facet joint pain has been determined to range between 7.7 and 75 . 13 rn m m m ra The diagnosis of zygapophyseal joint pain on clinical grounds is challenging. Historically, a patient who had a clinical presentation of low back pain and a normal neurologic examination was diagnosed with an arthropathy of a lumbar zygapophyseal joint. However, provocative...

Lumbar Plexus And Branches

Femoral Nerve Diagram

Innervation of the skin, muscles, periosteum, and joints of the hip, thigh, and knee make the blockade of the lumbar plexus particularly useful in pediatric patients. Analgesia for lower extremity procedures in children frequently involves areas innervated by branches of the lumbar plexus. Procedures involving joint or bone realignment, especially with insertion of hardware, are common, particularly in a disabled child whose ability to sit upright in a wheelchair or to manage transfers from...

Lumbar Sympathetic Ganglion Block

If the pain originates from the anterolateral portion of the lumbar vertebrae, a lumbar sympathetic ganglion block may bring relief. If there is consistent relief from the pain, a continuous technique or neurolytic technique is indicated. For a discussion on the techniques, refer to the section on the lower extremity. FIRST AND OR SECOND LUMBAR NERVE ROOT BLOCK As discussed earlier, the innervation of the anterolateral portion of the lumbar vertebral bodies and discs is from the first or second...

Magnetic Resonance Imaging

Magnetic fields and radio waves are used to measure and analyze multiple tissue parameters such as hydrogen (proton) density, T1 and T2 relaxation times of tissue, and tissue blood flow. Magnetic resonance (MR) provides soft tissue contrast, which is significantly better than any other imaging technique. The tissues are identified by characteristic differences of the T1 and T2 relaxation times. T1 measures how quickly the proton can be magnetized and T2 measures...

Maintenance Infusion

Adapted from Riley ET, Rose BK Epidural and spinal analgesia anesthe sia. II. Opioid techniques. In Chestnut DH (ed) Obstetric Anesthesia Principles and Practice, 2nd ed. St. Louis, Mosby, 1999 pp 386-408 and from Naulty JS Continuous infusions of local anesthetics and narcotics for epidural analgesia in the management of labor. Int Anesthesiol Clin 28 17, 1990. spinal. Bupivacaine requirements are less with epidural than with intravenous fentanyl.113 1121 spinal. Bupivacaine requirements are...

Management Of Intraspinal Baclofen For Spinal Spasticity

Baclofen, although not an analgesic per se, has been a most remarkable active spinal agent. Because oral baclofen does not readily cross the blood-brain barrier owing to its high molecular weight and hydrophilicity, and because high doses are needed for clinical efficacy, its use is limited by the development of intolerable central nervous system side effects. Administered directly to the spinal axis, intrathecal baclofen is quite effective at low doses that do not readily produce central...

Management Of Nonopioid Spinal Analgesia

Because many patients develop tolerance to opioid analgesics, have neuropathic pain that is less responsive to opioids, or develop these pain syndromes during intraspinal opioid therapy, it has become very clear that intraspinal opioid therapy alone is not sufficient to provide adequate analgesia for many patients. Therefore, scientists and clinicians are looking for other intraspinal, pharmacologic solutions for patients with these opioid-resistant pain syndromes. Physicians, however, must...

Management Of Unsuccessful Block

An alternate technique should be chosen. The structures of the head and neck are supplied by twelve cranial and four cervical nerves. A large proportion of the nerve supply to the head and neck is of a specialized sensory or secretomotor nature and is of minimal relevance to the practice of regional anesthesia. Another unique feature is the separation of sensory and motor functions, which allows anesthesia of the Figure 20-7 Line drawing of innervation of the...

Maternal Morbidity

Complications Related to Regional Anesthesia Techniques in Nonobstetric Patients A retrospective 1987 to 1990 review of 4767 consecutive spinal anesthetics,1 performed at the Mayo Clinic in the United States, for genitourinary and lower extremity orthopedic procedures, revealed a low incidence of paresthesias during needle placement (6 ) and postdural puncture headache (PDPH) (1 ). Six patients reported pain after resolution of the block, which slowly resolved 1 week to 24 months later, and, in...

Mechanism Of Action

Regional Anesthesia Mechanism

Glutamate and aspartate are arguably the major excitatory transmitters in the vertebrate central nervous system, whereas GABA is a major inhibitory transmitter. The cell surface receptors that mediate the effects of glutamate release can be found at most excitatory synapses throughout the central nervous system. These receptors they are divided into the slow, G-protein-coupled metabotropic receptors and the fast, ligand-gated ion channels (ionotropic receptors). The latter class is again...

Meninges Of The Spinal Cord

In the vertebral canal, the spinal cord is covered by three membranes (1) the dura mater is the tough, outer, protective membrane (2) the pia mater is the inner, delicate, fibrous membrane that contains the blood vessels to the spinal cord and (3) the arachnoid Figure 18-1 Normal curvature of the vertebral column. In the supine position, lumbar and cervical lordosis decreases (as shown by the arrows). Local anesthesia injected in the lumbar region settles around the T5 level because of the...

Meperidine

Meperidine is a phenylpiperidine derivative with physical characteristics, molecular weight, and pk similar to those of local anesthetics. It is the only opioid agonist clinically available that is known to be efficacious as a sole subarachnoid anesthetic. Surgical procedures to the lower limbs, the inguinal area, the perineum, and even cesarean section can be performed under spinal meperidine alone. ia Subarachnoid administration of 0.5 mg kg meperidine produces anesthesia with an onset of...

Methodology Issues In Evaluating Chronic Pain

The primary problem in evaluating chronic pain is to define relevant outcome measures that can provide an estimate of success of treatment consistent with the therapeutic procedure. Caution needs to be exercised in collecting, analyzing, and interpreting outcome data because of two important conceptual concerns. First, there are no satisfactory objective indicators of pain that are universally applicable and acceptable. Second, every outcome is prone to some degree of error during design,...

Midline Approach

The patient can be positioned in a lateral decubitus or sitting position. The position chosen depends on the ease with which the intervertebral spaces are palpated and identified. If the operator is not sure of the midline connecting the spinous processes, a sitting position for the patient has the decided advantage. The technique up to this point of needle entry is the same as that for spinal anesthesia. A 16- to 18-G Tuohy needle with a Huber point is generally used for the midline approach....

Morphine

Morphine remains the gold standard of spinally administered opioid therapy, because of its long duration of action and relative ease of use. Morphine has an extensive history more is known in the literature about the use of intraspinal morphine than about any other available opioid. In the United States, only morphine has been approved for clinical intraspinal analgesia. However, based on the literature and sound clinical judgment, other opioids are used intraspinally when patients do not...