NEW AND EMERGING CONCEPTS IN NERVE

BLOCKSPRESENTER-DR. ANAMIKA YADAV

TOPICS TO COVER 1.NEW EQUIPMENTS- A.ECHOGENIC NEEDLES,ECHOGENIC CATHETERS AND SENSe B.ULTRASONIC DEVICES-3D,4D,GPS AND CORDLESS USG DEVICES C.PRESSURE MONITORING DEVICES

2.LEARNING TOOLS- A.PHANTOMS B.ROBOTS

3.PHARMACOLOGY- A.LIPOSOMAL BUPIVACAINE B.PROLIPOSOMAL ROPIVACAINE C.ADJUVANTS TO PROLONG PERIPHERAL NERVE BLOCKS

TOPICS TO COVER 4.NEWER NERVE BLOCKS- A.ERECTOR SPINAE BLOCK B.RHOMBOIDES BLOCK C.SHAMROCK BLOCK D.ARTICULATING BRACH OF FEMORAL NERVE BLOCK E.TRANSVERSALIS FASCIA PLANE BLOCK F.COSTOCLAVICULAR BLOCK

5.LIA-LOCAL INFILTRATION ANALGESIA 6.SOME NEW TECHNIQUES IN PAIN MEDICINE POSTAMPUTATION PAIN T/T FREEZING SENSORY NERVE BLOCK PRIOR TO KNEE SX /CRYOANALGESIA

ECHOGENIC NEEDLES AND CATHETERSECHOGENIC NEEDLES ARE MADE SO AS TO INCREASE THE REFLECTION OF ULTRASONIC WAVES BACK TO THE TRANSDUCER

THIS IS ACHIEVED BY INCREASING THE VISUAL CONTRAST BETWEEN THE NEEDLE AND THE SURROUNDING TISSUE BY- COATING THE NEEDLE WITH TEFLON OR POLYMER ,TEXTURING,DIMPLING,ROUGHENING ETC

THESE NEEDLES PRODUCE FEWER ARTIFACTS AND HAVE A REDUCED IMPACT ON THE NEEDLE HANDLING AND FEEL. Limited data exist regarding the echogenicity of perineural catheters, but visualization is crucial to ensure accurate placement and efficacy of the subsequent local anesthetic infusion.

SOME EXAMPLES OF ECHOGENIC NEEDLES

ECHOGENIC CATHETERS Includes: 20 Ga. x 55 cm Contiplex Echo Open-tip Catheter with Stylet and Threading Assist Guide, Contiplex Tuohy Ultra Needle, Sideport Valve, and Catheter Connector

SENSE(SEQUENTIAL ELECTRICAL NERVE STIMULATION) Alternating sequential electrical pulses(3) of differing pulse durations at a set frequency of 3 Hz

High pulse durations increase sensitivity

The third impulse has longer reach into the tissue.

Muscle twitches at 3Hz per second indicate needle is positioned closer to the nerve

The impulse duration of the third impulse decreases with stimulus amplitude below 2.5 mA

SENSE…ADVANTAGES Clinically, there is more motor response information at distance from the nerve. Moving

the needle toward the nerve increases the strength or frequency of the motor response.

Continuous feedback and markedly diminishes the disappearance of motor responses once they are encountered

Increases visual clues and feedback

Less necessity to adjust the amperage control of the nerve stimulator.

ULTRASONOGRAPHY ADVANCES 1.3D USG

2.4D USG

3.GPS IN USG

4.HANDHELD USG( iPhone iPad laptop)

5.WIRELESS PROBES

USG… 3D-Mechanical/matrix probe Mechanically swept transducer inside a standard probe that moves through a known trajectory –obtains 2D scans that are converted to 3D images

Matrix array transducer utilizes more than 2400 peizo electric elements –acquire a direct 3D image

4D-Simultaneous visualisation of multiple planes of view Spatial relationship between anatomical structures of interest Measuring local anesthetic spread and tracking fluid dissipation in fascial compartments

GPS USG-Electromagnetic sensors are mounted on both the transducer and needle tip

These sensors enable the device to determine actual needle tip position in relation to the transducer

USG ADVANCES..ADVANTAGES 3D-PROVIDES MORE DETAILED ANATOMICAL INFORMATION AND BETTER SPATIAL ORIENTATION THAN 2D IMAGE.

4D-IT ENHANCES THE VISUALISATION OF A PARTICULAR ANATOMY AND OFFERS REAL TIME ASSESSMENT OF LOCAL ANESTHETIC SPREAD DURING USG RA TECHNIQUES.(BASICALLY A LIVE 3D WHERE TIME IS THE FOURTH DIMENSION)

GPS IN USG-ELECTROMAGNETIC TRACKING CAN FACILITATE NEEDLE BEAM ADJUSTMENTS FOR IN PLANE APPROACH AND INDICATES WHERE THE NEEDLE CROSSES THE BEAM DURING OUT OF PLANE USG TECHNIQUE.

HANDHELD USG AND CORDLESS PROBE ALLOWS EASY USE AND EASY AVAILABILITY AND PORTABILITY ,CAN BE USED DURING EMERGENCY LIKE TRAUMA CASES FOR AIRWAY ANATOMY,IN CASES OF EMERGENCY TRACHEOSTOMY OR CASES WITH DISTORTED AIRWAY ANATOMY.(MATRIX TRANSDUCERS ARE LIGHTER)

PRESSURE MONITORING DEVICES These are disposable manometer to monitor injection pressure during performance of peripheral nerve blocks.

It provides visual indication of injection pressure. The syringe feel method for assessing the injection force is inconsistent and thus this provides objective method of monitoring and documenting injection pressure irrespective of who performs it.

One such example is B-Smart injection pressure monitor. Intrafascicular injections->15 Psi-associated with severe fascicular injury and persistent neurological deficits

97% detection of needle nerve contact (>=15 Psi),intraneural inflammatory changes Perineural injections typically <4 Psi Thus is a preventable complication.

HOW TO USE IT? Priming the B-Smart Pressure Monitor 1. Attach the B-Smart monitor to filled syringe 2. Attach needle tubing to the B-Smart monitor 3. Flush system, ensuring the B-Smart monitor’s piston rises so “> 20 psi” (orange) is visible. The B-Smart monitor’s piston must move upward during priming in order for the device to be ready to use. It may be helpful to obstruct the injection tubing to accomplish this.

- 20 psi

- 20 psi

- 20 psi

LEARNING TOOLS-PHANTOMS Calibration and testing of diagnostic ultrasound machines requires accurate

representation and sonographic characteristics of human tissue. The physical properties, including speed of sound and attenuation, are tailored to be

the same as those of human tissue TYPES OF PHANTOMS-• Water• Agar• Gelatin Elastomeric rubber-BLUE PHANTOMS (BETTER TACTILE FEEDBACK,NO REFRIGERATION

REQD. AND LESS NEEDLE TRACK ARTIFACTS,REUSABLE MULTIPLE TIMES BUT EXPENSIVE AND DIFFICULT TO PREPARE)

Other option-• Meat and Cadavers.

PHANTOMS-PROPERTIES OF A GOOD PHANTOM-ECHOGENECITY OF HUMAN TISSUE,READILY AVAILABLE,INEXPENSIVE,REUSABLE,GIVES TACTILE FEEDBACK,HOLDS NEEDLE IN PLACE AND DOESN’T GENERATE NEEDLE TRACKS AND NO EXPOSURE TO HEALTH HAZARDS.

Water phantoms- development and investigation of new UGRA techniques

Non-meat- practising needle placement

Meat based-realistic tissue feedback,local anaesthetic injection

Cadaver based-realistic environment

Sample sonogram of a nonanatomic inorganic phantom for ultrasound-guided regional anesthesia.

Sample sonogram of an organic phantom for ultrasound-guided regional anesthesia using a porcine meat specimen with inserted bovine tendon to represent the target “nerve” (arrowheads identify the tendon).

LEARNING TOOLS-ROBOTSMAGELLAN ROBOTIC NERVE BLOCK SYSTEMPARTS-1.Thrustmaster-joystick with two handles

2. JACO-Robotic arm

3. Software control system

4. Graphical user interface

ADVANCES IN PHARMACOLOGY A.LIPOSOMAL BUPIVACAINE (EXPAREL-Brand name)

Liposomes are microscopic structures consisting of a phospholipid bilayer encapsulating an aqueous core

UNILAMELLAR-single lipid bilayer surrounding the aqueous core

MULTILAMELLAR-concentric lipid bilayers

MULTIVESICULAR-nonconcentric lipid bilayers

LIPOSOMAL BUPIVACAINE LIPOSOMAL BUPI IS FORMULATED TO DELIVER BUPI SLOWLY OVER TIME TO EXTEND ITS DURATION OF ACTION.

DEPOFOAM IS A PRESERVATIVE FREE AQUEOUS SOLUTION OF MULTIVESICULAR LIPOSOMES CONTAINING BUPI AT A CONCENTRATION OF 13.3 MG/ML(EXPRESSED AS AN ANHYDROUS BUPI HCL EQUIVALENT )AND PLUS 3 % FREE BUPIVACAINE.

THIS FORMULATION PRODUCES TWO PEAKS ONE AFTER FREE BUPIVACAINE ACTS (FIRST ORDER RELEASE) AND OTHER AFTER GRADUAL RELEASE OF BUPIVACAINE (SECOND ORDER RELEASE).

TMAX (TIME TO PEAK PLASMA CONC.) IS 12 HR FOR LIPOSOMAL BUPI V/S 0.6 HR FOR BUPI HCL.

PEG LIPOSOMES...

BIOFUNCTIONALIZING THE LIPOSOMES WITH POLYETHYLENE GLYCOL(PEG),PREVENTS THE INTERACTION BETWEEN THE LIPOSOMAL NANOVESICLES AND THE MONONUCLEAR PHAGOCYTIC SYSTEM AND OBTAINS A HIGHER PHARMACOKINETIC RESPONSE.

PROLIPOSOMAL ROPIVACAINE NEW PRODUCT DEVELOPED AND TESTED BY DR. YEHUDA GINOSAUR OF HEBREW UNIVERSITY,JERUSALEM.FIRST TESTED IN PIGS WHERE SINGLE DOSE STAYED FOR 4 DAYS THEN IN HUMANS.

IN HUMANS AFTER INJECTION ANESTHESIA TO PINPRICK LASTED ON AN AVG OF 29 HRS V/S 16 HRS IN PLAIN ROPIVACAINE.

FOR HEAT AND PAIN SENSATION IT LASTED FOR 36 HRS V/S 12 HRS FOR PLAIN BUPIVACAINE.

BUT IN THIS TEST 4 % ROPIVACAINE FORMULATION WAS USED, ALMOST 8 TIMES THE DOSE NORMALLY USED.

PROLIPOSOMAL ROPIVACAINE

ADVANTAGES OVER OTHER LIPOSOMAL AND PLAIN PREPARATIONS-

IT DOESNOT BECOME LIPOSOMAL UNTIL INJECTED AND CAME IN CONTACT WITH AQUEOUS SOLUTION I.E, PLASMA AND HENCE THE NAME PROLIPOSOMAL.

CURRENT LIPOSOMAL PPTNS HAVE A SHELF LIFE OF 1-2 MONTHS AND PROLIPOSOMAL ROPIVACAINE OIL HAS A SHELF LIFE OF 2 YEARS EVEN AT ROOM TEMPERATURE.

IT IS ALSO EASY TO PREPARE. IT COULD SIGNIFICANTLY EXTEND DURATION OF PAIN CONTROL AFTER INFILTRATION OF LOCAL ANESTHETICS-A WORTHY BUT SO FAR ELUSIVE GOAL.

Liposome-encapsulated ropivacaine for topical anesthesia of human oral mucosa.

Franz-Montan M1, Silva AL, Cogo K, Bergamaschi Cde C, Volpato MC, Ranali J, de Paula E, Groppo FC.

Adductor Canal Block With Bupivacaine Liposome Versus Ropivacaine Pain Ball for Pain Control in Total Knee Arthroplasty: A Retrospective Cohort Study.

Wang Y1, Klein MS2, Mathis S2, Fahim G3.

Liposomal bupivacaine demonstrated statistically significant impact in pain control in the first 36 hours, but by the end of the 72-hour interval, it was comparable to RPB in postoperative pain management. Using bupivacaine liposome did provide direct and total cost savings compared with RPB.

ADJUVANTS TO PROLONG PERIPHERAL NERVE BLOCKS Many studies have been done on adjuvants to local anesthetics to prolong action of nerve blocks.

Various adjuvants studies are many as follows- 1.DEXAMETHASONE 2.CLONIDINE 3.DEXMETEDOMIDINE 4.SODIUM BICARBONATE 5.EPINEPHRINE 6.MAGNESIUM 7.MIDAZOLAM 8.TRAMADOL 9.BUPRENORPHINE 10.KETAMINE

ADJUVANTS… DEXAMETHASONE-10 mg dose prolongs action by 10 hrs acc to one study but no definitive and detailed study available,maximum clinical trials have found it to be not so effective.

CLONIDINE-150 mcg dose prolonged analgesia in one study by 2 hrs,one more study showed shorter motor blockade duration when added to ropivacaine than with bupivacaine, but found to have neurotoxic effects according to another study.

SODIUM BICARBONATE-found to have shorter onset time in a study but overall in others no significant increase in duration of action ,neurotoxicity profile unknown.

EPINEPHRINE-prolongs duration of action of LA but decreases blood supply to neural tissue,still recommended as IV injection marker in dose of 2.5mcg/ml ,if giving in block in ways other than USG recommendation is 1 in 4 lac concentration.

ADJUVANTS MAGNESIUM-prolongs duration of action but further studies required for its efficacy and neurotoxicity profile.

MIDAZOLAM -not recommended infact found to be neurotoxic.

KETAMINE- not recommended infact found to be neurotoxic.

BUPRENORPHINE-prolongs analgesic action by 12 hrs but side effects nausea vomiting are distressing,also not studied in detail.

TRAMADOL-in dose of 1.5 mg/kg has not been found to be very efficacious.

DEXMEDETOMIDINE Study by Kettner et al in Austria shows a significant increases in duration of action when added in peripheral nerve blocks .

It acts by blocking the hyperpolarization activated cation current in the peripheral nerves,renders them refractory to stimulation.

Fristch et al found 150 mcg hastened sensory and motor block and prolongation by 240 min with no hemodyanamic instability.

Marhofer et al found as low as 20 mcg prolonged ulnar nerve sensory block by 248 min and motor block by 205 min.

Sandhya Agarwal et al found 100 mcg shortens the onset time and prolonged the duration of action significantly when mixed with 0.325 % bupivacaine ,755 min sensory v/s 234 min and 702 min for motor block v/s 208 min.

Surprisingly,both motor and sensory block prolongation found with iv administration of dexmed 20 mcg by 45 and 90 min respectively.(FDA approved)

It appears to be a promising upcoming drug for peripheral nerve blocks.

NEW NERVE BLOCKS…

ERECTOR SPINAE BLOCK ERECTOR SPINAE MUSCLE ORIGINATES FROM SPINOUS PROCESS OF T9 TO T12 THORACIC VERTEBRAE AS WELL AS THE MEDIAL SLOPE OF THE DORSAL SEGMENT OF THE ILIAC CREST.

IT GETS INSERTED TO THE SPINOUS PROCESS OF T1 AND T2 THORACIC VERTEBRAE AND THE CERVICAL VERTEBRAE AS WELL.

IT IS A GROUP OF MUSCLES ,ILIOCOSTALIS LATERALLY,LONGISSIMUS INTERMEDIATE AND SPINALIS MEDIALLY.

IT RUNS THROUGHOUT LUMBAR,THORACIC AND CERVICAL REGION IN GROOVE TO THE SIDE OF THE VERTEBRAL COLUMN.

https://en.wikipedia.org/wiki/File:Gray389_-_Erector_spinae.png

ERECTOR SPINAE BLOCK DESCRIBED BY MAURICIO FORERO ET AL

IT’S A MULTIDERMATOMAL SENSORY BLOCK T2-T9

ACTS ON DORSAL AND VENTRAL RAMI OF THORACIC SPINAL NERVES

BENEFITIAL FOR NEUROPATHIC PAIN LIKE METASTASIS TO RIBS OR MALUNION AFTER MULTIPLE RIB FRACTURES,POSTSURGICAL AND POST TRAUMATIC PAIN.

PROVIDES PAIN RELIEF UPTO 36 HOURS.

ERECTOR SPINAE BLOCK TECHNIQUE-PROBE IS PLACED IN LONGITUDINAL ORIENTATION OVER TIP OF T5 TRANSVERSE PROCESS AND BOCK NEEDLE IS ADVANCED CEPHALAD TO CAUDAD DIRECTION TO CONTACT THE TRANSVERSE PROCESS THEN WITHDRAWN TO GIVE DRUG.

DRUG CAN BE DEPOSITED EITHER ABOVE ERECTOR SPINAE(TYPE 1,LESS EFFICACIOUS)

OR CAN BE DEPOSITED BELOW ERECTOR SPINAE AND TRANSVERSE PROCESSES(TYPE 2,MORE LINEAR SPREAD WITH BETTER RESULTS)

AREA COVERED-T2-T9 ,3CM LATERAL TO THE THORACIC SPINE TO MIDCLAVICULAR LINE,ALSO AXILLA AND MEDIAL UPPER PART OF ARM GETS THE SENSORY BLOCKADE

DRUG -0.25 % BUPIVACAINE 20 ML 6-13 MHZ LINEAR USG PROBE IN SITTING POSITION.

T4T5

ES

RHOIMBOIDES

TRAPEZIUS

NEEDLE INSERTED TO T5 AND THEN WITHDRAWN

T5LA SPREAD

ADVANTAGES OF ERECTOR SPINAE BLOCK EASY SONOANATOMY

SAFER AND SIMPLE BLOCK V/S INTERCOSTAL AND PARAVERTEBRAL WHICH ARE MORE INVASIVE THUS CAN BE USED AS AN OPD BLOCK.

PECTORAL AND SERRATUS ANTERIOR BLOCK DOESNOT COVER THE VAST SENSORY BLOCK AREA V/S ERECTOR SPINAE BLOCK AS IT COVERS AXILLA AND ANTEROLATERAL CHEST WALL AREA AS WELL.

CATHETER CAN BE PUT FOR LONG TERM USE AS WELL.

MORE STUDIES ARE REQUIRED TO CHECK ITS EFFICACY.

RHOMBOIDES BLOCK DESCRIBED BY H.ELSHARKAWY ET AL. PECTORAL AND SERRATUS PLANE BLOCK DON’T COVER THE POSTERIOR PRIMARY RAMI WHICH CAN BE ACHIEVED BY INFILTRATION OF LOCAL ANESTHETICS INTO INTERFASCIAL PLANE ON POSTERIOR CHEST WALL IN TRIANGLE OF AUSCULTATION (TOA)KNOWN AS RHOMBOIDES BLOCK.

TOA IS LOCATED ALONG LOWER MEDIAL BORDER OF SCAPULA BOUNDARIES- SUPERIORLY-TRAPEZIUS INFERIORLY-LATISSIMUS DORSI LATERALLY-VERTEBRAL BORDER OF SCAPULA FLOOR IS FORMED BY LOWER PART OF RHOMBOID MAJOR,LATERAL PART OF ERECTOR SPINAE AND SERRATUS ANTERIOR MUSCLES OVERLYING 6TH TO 7TH RIBS AND THEIR INTERNAL AND EXTERNAL INTERCOSTAL MUSCLES.

RHOMBOIDES BLOCK TISSUE PLANE BETWEEN FLOOR OF TOA (RHOMBOIDES MAJOR) AND THE INTERCOSTALS EXTENDS MEDIALLY BELOW ERECTOR SPINAE,LATERALLY CROSSES MIDAXILLARY LINE BELOW SERRATUS ANTERIOR.

PATIENT POSITION-PRONE AND ARMS ADDUCTED ACROSS THE CHEST TO PUSH THE SCAPULA LATERALLY.

LINEAR USG PROBE (6-13 MHZ) PLACED MEDIAL TO THE LOWER BORDER OF SCAPULA WITH THE MARKER DIRECTED CRANIALLY.

PLANE IS IDENTIFIED ,SINGLE INJECTION GIVEN AT T6-T7 LEVEL 25 ML OF 0.25 % BUPIVACAINE AREAS COVERED-T2-T9 ,ANTERIOR HEMITHORAX JUST MEDIAL TO THE MIDLINE ,LATERAL FROM AXILLA TO T9 AND POSTERIOR HEMITHORAX UPTO MEDIAL OF THE MIDLINE.THUS COVERS MORE AREA V/S ERECTOR SPINAE.

FURTHER MORE STUDIES ARE REQUIRED LOOKS PROMISING.

ARTICULATING BRANCH OF FEMORAL NERVE (ABFN)BLOCK It is a new block ,few studies done and shown to have a good post operative pain relief profile in patients undergoing Hip Arthroplasty (as necessity of good pain relief as well as mobilisation)

This block involves very less side effects. Anatomy of ABFN- ANTERIORLY-SARTORIUS LATERALLY-RECTUS FEMORIS MEDIALLY-ILIACUS

ABFN … Typically Obturator nerve block was used to relieve hip pain uptil now but found to have a lot of sparing.

This led to some anatomical studies eg K.Birhaum et al who concluded following-

HIP JOINT CAPSULE SUPPLY- ANTEROMEDIAL-ARTICULAR BR OF OBTURATOR NERVE ANTERIOR-SENSORY ARTICULAR BR OF FEMORAL NERVE(ABFN) POSTERIOR-ARTICULAR BR OF SCIATIC NERVE POSTEROMEDIAL-ARTICULAR BR OF NERVE TO QUADRATUS FEMORIS THUS FOR COMPLETE PAIN RELIEVE NEED TO BLOCK ALL THREE-OBTURATOR,FEMORAL AND SCIATIC ARTICULAR BRANCHES.

Femoral n. with three articular branches (arrow)

ABFN TECHNIQUE LANDMARK-3-4 CM CAUDAL TO THE INGUINAL LIGAMENT PROBE-LINEAR 6-13 MHZ DRUG-20 ML 0.25 % BUPIVACAINE AND 4 MG DEXAMETHASONE TECHNIQUE-OUT OF PLANE USG GUIDED NEEDLE-3.5CM HYPODERMIC 23 G NEEDLE IDENTIFICATION-IT’S A HYPERECHOIC TRIANGULAR TO OVAL STRUCTURE,0.5-1 CM IN DIAMETER

REPRESENTATION OF ABFN AND ITS RELATION TO MUSCLES AND FEMORAL VESSELS AND NERVE

SARTORIUS

RECTUS FEMORIS

AB

FA

SARTORIUS

ILIACUSRECTUS FEMORIS

ARTICULATING BRANCH OF FEMORAL NERVE

SHAMROCK BLOCK TRANSVERSE USG SCAN ,PROBE IS PLACED CRANIALLY TO THE ILIAC CREST ,FOR LUMBAR PLEXUS BLOCK

FIRST DESCRIBED IN 2013 BY SAUTER ET AL PSOAS MAJOR MUSCLE IS SEEN ANTERIOR TO THE TRANSVERSE PROCESS,ERECTOR SPINAE IS POSTERIOR TO THE TRANSVERSE PROCESS,QUADRATUS LUMBORAM IS AT THE APEX OF THE TRANSVERSE PROCESS L4

EASILY RECOGNISABLE PATTERN OF SHAMROCK,THREE LEAVES IS SEEN ON USG

DEPOSIT LA POSTERIOR TO THE PSOAS MAJOR MUSCLE.

The Shamrock lumbar plexus block: A dose-finding study.

Sauter AR1, Ullensvang K, Niemi G, Lorentzen HT, Bendtsen TF, Børglum J, Pripp AH, Romundstad L.

Author information

A volume of 20.4 ml ropivacaine 0.5% provided a successful Shamrock lumbar plexus block in 50% of the patients. A volume of 36.0 ml would be successful in 95% of the patients.

COSTOCLAVICULAR BLOCK(PROXIMAL APPROACH OF INFRACLAVICULAR BLOCK) COSTOCLAVICULAR SPACE BOUNDARIES-deep and posterior to middle of clavicle

ANTERIORLY-CLAVICLE MEDIALLY-FIRST RIB POSTERIORLY-SCALENUS ANTERIOR LATERALLY-COSTOCLAVICULAR LIGAMENT AND SUBCLAVIUS MUSCLE CONTENTS- BRACHIAL NERVE PLEXUS AXILLARY ARTERY AXILLARY VEIN

COSTOCLAVICULAR BLOCK…

COSTOCLAVICULAR BLOCK… ADVANTAGES- AS COMPARED TO INFRACLAVICULAR FOSSA LATERALLY, HERE ALL THREE CORDS ARE QUITE SUPERFICIAL AND CLUSTERED TOGETHER,LATERAL TO AXILLARY ARTERY.

VERY RAPID ONSET SIMILAR TO SUPRACLAVICULAR BLOCK AND ALSO LESS CHANCES OF SPARING OF THE LOWER TRUNK.

CATHETER CAN BE PLACED EASILY AND THAT TOO VERY CLOSE TOO ALL THREE CORDS.

CATHETER DISPLACEMENT CHANCES ARE MINIMAL AS LIES DISTALLY IN INTERMUSCULAR TUNNEL (SUBCLAVIUS AND SERRATUS ANTERIOR MUSCLES).

TRANSVERSALIS FASCIA PLANE BLOCK The transversalis fascia plane block, or TFP block, is a truncal block that targets the L1 nerve branches, namely the ilioinguinal and iliohypogastric nerves.

These nerves emerge from the lateral border of psoas major muscle, inferior to the 12th rib, and course over the anterior surface of the quadratus lumborum muscle finally enter the transversus abdominis plane between the internal oblique and transversus abdominis muscles.

The TFP block targets the ilioinguinal and iliohypogastric nerves where they are between the fascia of the transversus abdominis muscle and the transversalis fascia.

The fascia of the transversus abdominis muscle, also called the thoracolumbar fascia, is formed when the transversus abdominis and internal oblique muscles taper off posteriorly into a common aponeurosis.

TFP INDICATIONS-

The TFP block is indicated for pain relief following anterior iliac crest bone graft harvesting as the block is performed proximal to the L1 branches that innervate the anterior iliac crest.

Local anesthetic spread can also involve the subcostal nerve (T12 spinal nerve). This block is also an analgesic option for inguinal hernia repair, open appendectomy and any surgery involving the L1 dermatome.

TFP V/S TAPThe TFP block is designed to block the L1 nerve branches, which the TAP block does not reliably cover.

Local anesthetic is injected deep to the transversus abdominis muscle for the TFP block versus superficial to the muscle for the TAP block.

The site of TFP injection is posterior to the mid-axillary line, unlike the classic ultrasound-guided TAP block.

Internal Oblique Muscle

Transversus Abdominis Muscle

External Oblique Muscle

External oblique m uscle

Internal oblique m usc

le

Transversus a bdominis

Quadratus l umborum

LOCAL INFILTRATION ANALGESIA-LIALocal infiltration analgesia (LIA) is an analgesic technique that has gained popularity since it was first brought to widespread attention by Kerr and Kohan in 2008. The technique involves the infiltration of a large volume dilute solution of a long-acting local anesthetic agent, often with adjuvants (e.g., epinephrine, ketorolac, an opioid), throughout the wound at the time of surgery. The analgesic effect duration can then be prolonged by the placement of a catheter to the surgical site for postoperative administration of further local anesthetic. The technique has been adopted for use for postoperative analgesia following a range of surgical procedures (orthopaedic<knee and hip surgeries>, general, gynecological, and breast surgeries).

Analgesic efficacy of local infiltration analgesia in hip and knee arthroplasty: a systematic review

1. L. . Andersen

2. H. Kehlet

LIA provides effective analgesia in the initial postoperative period after TKA in most randomized clinical trials even when combined with multimodal systemic analgesia.

Local infiltration analgesia: a technique for the control of acute postoperative pain following knee and hip surgery: a case study of 325 patients.

Kerr DR1, Kohan L.

Local infiltration analgesia is simple, practical, safe, and effective for pain management after knee and hip surgery.

LIA..ADVANTAGES IT ALLOWS EARLY MOBILISATION. IT SAVES THE HOSPITAL COSTS AS EARLY DISCHARGE. INVOLVES NO COMPLICATIONS LIKE HYPOTENSION,QUADRICEPS MUSCLE WEAKNESS,URINARY RETENTION ETC.

A NUMBER OF INVESTIGATORS HAVE FOUND LIA TO BE SUPERIOR TO PLACEBO/NO INFILTRATION AND EPIDURAL ANALGESIA IN TERMS OF POSTOPERATIVE ANALGESIA SCORES,JOINT FUNCTION/REHABILITATION,AND LENGTH OF HOSPITAL STAY.

Peripheral nerve blockade (PNB) has been shown to provide equivalent analgesia compared to epidural analgesia with the benefit of a lesser incidence of hypotension and urinary retention , however PNB requires a high level of expertise to perform,?QUADRICEPS WEAKNESS.

Choi et al. reviewed the use of epidural analgesia for pain relief following hip (and knee) replacement in a Cochrane review in 2003 and concluded that the beneficial effect of epidural analgesia was limited to 4–6 hours postoperatively, and side effects (hypotension, pruritus, urinary retention) were more frequent with epidural analgesia compared to systemic analgesia

OTHER NEWER TECHNIQUES IN PAIN MEDICINE Postamputation residual limb pain is often a disabling chronic pain that is refractory to current pain management modalities, such as medications, peripheral nerve blocks or denervation,Using high-frequency alternating current via a peripheral nerve cuff electrode creates a complete depolarizing nerve block, which blocks painful or unwanted nerve transmission of pain signals; the cuff is placed proximal to the neuroma at the end of the severed nerve. This therapy yielded >50% pain reduction.More studies required.

PERCUTANEOUS FREEZING OF SENSORY NERVES PRIOR TO TKR Percutaneous cryoneurolysis targeting the infrapatellar branch of the saphenous nerve and anterior femoral cutaneous nerve could relieve post-operative knee pain by temporarily blocking sensory nerve conduction. The treatment group reported a statistically significant reduction in symptoms at the six- and 12-week follow-up compared with the control group.More studies are required.

PAIN MEDICINE… Cryoanalgesia involves a cryogenic probe under direct fluoroscopy guidance. A local anaesthetic is used in this procedure to numb the skin and underlying tissues. A catheter is then inserted into this area. A cryobrobe is threaded through the catheter. Once the specific nerve area is identified, the freezing process begins(less than -20 degree Celsius is effective). This can take 2-3 minutes and may be repeated in order to cover one’s pain.

Cryoanalgesia can be utilized for treating small well localized lesions of nerves, perineal pain, lower extremity pain, post-herpetic neuralgia , and facial and cranial pain.

It has also been used to obtain pain relief in biomechanical pain syndromes including lumbar or cervical facet syndromes, and coccygodynia, and to treat post-surgical pain .

The most common use for cryoanalgesia for lower back pain is the long term treatment of lumbar facet pathology.

PRACTICE MAKES A MAN AS WELL AS A WOMAN PERFECT