UNASSIGNED: The epidural injections used to treat lumbar radiculopathy are potentially associated with serious complications like neurological injuries and epidural abscess. The nociceptors have the unique property of being pseudo-unipolar, as its both ends are expected to be functionally same. We have hypothesized that peripheral nerve blocks given at the distal site should be able to provide pain relief. This prospective study was planned to assess the efficacy of peripheral nerve blocks in lumbar radiculopathy.
UNASSIGNED: Thirty-four patients who fit the eligibility criteria were included in this open labeled prospective preliminary study. They were administered peripheral nerve blocks at ankle level with 4 ml of 0.25% bupivacaine and 40 mg of triamcinolone.
UNASSIGNED: The outcomes measured at 15 days, 1 month, 2 months, and 3 months after the intervention were the pain intensity (Numerical Rating Scale), the Global Perceived Effect, functional status (Roland Morris Disability Questionnaire), Beck\'s Depression Inventory score, employment status, and analgesic intake.
UNASSIGNED: At 15 days, 1 month, and 2 months, 88% of the patients reported a ≥50% decrease in their pain scores and a GPE ≥6, while at 3 months 85% of the patients reported a significant decrease in their pain scores and a GPE ≥6.
UNASSIGNED: Peripheral nerve blocks are effective in the management of pain in patients with chronic lumbosacral radiculopathy. The ability to administer it in an outpatient setting, without image guidance and the absence of debilitating side effects, makes it an attractive treatment option.

BACKGROUND: Many regional anaesthetic techniques have been proposed to manage pain after total knee arthroplasty, but the best approach is unclear. We compared opioid consumption in the first 48 h between two different regional anaesthesia strategies in patients undergoing total knee arthroplasty.
METHODS: In this single-centre, prospective study, we randomly allocated 90 patients to a combination of IPACK (interspace between popliteal artery and capsule of the posterior knee), triangle femoral and obturator nerve blocks (distal group), or a combination of sciatic, femoral, obturator, and lateral femoral cutaneous nerve blocks (proximal group). All patients received an opioid-sparing general anaesthesia regimen. The primary outcome was opioid consumption in the first 48 h. Secondary outcomes included opioid consumption in the first 24 h and verbal rating pain scores in the first 48 h.
RESULTS: There was no difference in median cumulative oral morphine equivalent consumption at 48 h between the distal and the proximal block groups (33 [18-78] mg vs 30 [22-51] mg, respectively; P=0.29). Median oral morphine equivalent consumption at 24 h was higher in the distal group compared with the proximal group (30 [13-59] vs 15 [0-18], respectively; P<0.001). Verbal rating pain scores were lower in the proximal group compared with the distal group on arrival to the postanaesthesia care unit and at 6 and 12 h.
CONCLUSIONS: In patients undergoing total knee arthroplasty under total intravenous general anaesthesia with a multimodal analgesia regimen, proximal nerve blocks resulted in improved pain scores in the first 12 h and reduced opioid consumption in the first 24 h when compared with distal nerve blocks. No difference in pain scores or opioid consumption was seen at 48 h.
BACKGROUND: NCT04499716.

BACKGROUND: Combined anesthesia can be a promising option for hip surgery when neuraxial anesthesia is contraindicated. Lumbar and sacral plexus blocks, and femoral nerve and lateral femoral cutaneous (LFC) nerve blocks in combination with general anesthesia (GA) are commonly used in elderly patients undergoing arthroplasty for hip fracture surgery. However, no study has compared these two anesthetic strategies in the perioperative period.
METHODS: A total of 41 elderly patients scheduled for arthroplasty for hip fracture surgery were randomized into group A (n = 20) and group B (n = 21). Group A received femoral nerve block, LFC nerve blocks, and GA, and group B received lumbar plexus block, sacral plexus block, and GA. Primary outcomes were incidences of hemodynamic events and changes in blood pressure (BP) and heart rate (HR). Secondary outcomes included time and drug consumption, infusion and bleeding volume, eyes opening time after surgery, and postoperative quality recovery rate.
RESULTS: Compared with group B, group A showed a lower incidence of intraoperative hypotension (p < 0.001), higher BP [including mean arterial pressure (MAP), systolic BP (SBP), and diastolic BP (DBP)] following induction (IN), and higher HR from mid-surgery. Time required for nerve blockade (p < 0.001) and ephedrine consumption was significantly shorter in group A (p < 0.001), while sufentanil consumption was higher as compared to group B (p = 0.002). No significant differences in other intraoperative parameters and postoperative quality recovery rate were reported during the observation.
CONCLUSIONS: Our pilot data indicate that compared with lumbar and sacral plexus blocks, femoral nerve and LFC nerve blocks may provide more stable intraoperative hemodynamics and a comparable postoperative recovery for elderly patients undergoing arthroplasty for hip fracture under GA. Further studies with a larger sample size are needed to derive stronger evidence.

Pain after lower limb orthopedic surgery can be severe. Poorly controlled pain is associated with adverse outcomes. Peripheral nerve blocks (PNB) have become popular in foot and ankle surgery for their effective pain control and low complication rates. It has always been assumed that hindfoot procedures are more painful than midfoot/forefoot procedures often requiring inpatient stay for pain relief. There are no published studies evaluating this assumption. To investigate whether hindfoot procedures are more painful than forefoot/midfoot procedures by measuring pain scores, assessing effectiveness of PNBs and patient satisfaction. One hundred forty patients undergoing elective foot and ankle surgery were prospectively studied. Inclusion criteria: Adults undergoing elective foot and ankle surgery. Exclusion criteria: Patients 16 years or under, those with alternate sources of pain, peripheral neuropathy, known substance abuse, psychiatric illness and incomplete pain scores. Pain was measured via the Visual Analog Scale at 3 time intervals: immediately, 6 hours and at 24 hours postoperatively. Analysis was via t-test. A p value of <.05 demonstrated a statistical significance. Forefoot/midfoot versus hindfoot surgery pain scores showed that there was no significant difference at any postoperative interval. PNB versus no PNB pain scores showed there was no significant difference, except at 24 hours postoperatively (p value .024). Patients who had a PNB experienced rebound pain at 24 hours. Hindfoot surgery is not more painful than forefoot/midfoot surgery. Patients who had a PNB experienced rebound pain at 24 hours postoperatively, a finding that requires further research.

OBJECTIVE: This study aimed to explore the efficacy and safety of the combination of lateral femoral cutaneous nerve blocks (LFCNB) and iliohypogastric/ilioinguinal nerve blocks (IHINB) on postoperative pain and functional outcomes after total hip arthroplasty (THA) via the direct anterior approach (DAA).
METHODS: In this retrospective cohort study, patients undergoing THA via the DAA between January 2019 and November 2019 were stratified into two groups based on their date of admission. Sixty-seven patients received LFCNB and IHINB along with periarticular infiltration analgesia (PIA) (nerve block group), and 75 patients received PIA alone (control group). The outcomes included postoperative morphine consumption, postoperative pain assessed using the visual analogue scale (VAS), the QoR-15 score, and functional recovery measured as quadriceps strength, time to first straight leg rise, daily ambulation distance, and duration of hospitalization. The Oxford hip score and the UCLA activity level rating were assessed at 1 and 3 months after surgery. In addition, postoperative complications were recorded. Patients were also compared based on the type of incision used during surgery (traditional longitudinal or \"bikini\" incision).
RESULTS: Patients in the nerve block group showed significantly lower postoperative morphine consumption, lower resting VAS scores within 12 h postoperatively, lower VAS scores during motion within 24 h postoperatively, and better QoR-15 scores on postoperative day 1. These patients also showed significantly better functional recovery during hospitalization. At 1-month and 3-month outpatient follow up, the two groups showed no significant differences in Oxford hip score or UCLA activity level rating. There were no significant differences in the incidence of postoperative complications. Similar results were observed when patients were stratified by type of incision, except that the duration of hospitalization was similar.
CONCLUSIONS: Compared to PIA alone, a combination of LFCNB and IHINB along with PIA can improve early pain relief, reduce morphine consumption, and accelerate functional recovery, without increasing complications after THA via the DAA.

UNASSIGNED: Regional anaesthesia techniques are a part of perioperative medicine that affects both perioperative and long-term outcomes. We have a paucity of the data on the usage and practices of plexus and peripheral nerve blocks (PNBs). To the best of our knowledge, this is the first effort to validate a survey for plexus and PNBs. Subsequently, this questionnaire could be used for the survey to look for the trends and disparities in PNB practices and further to develop a national registry in the future.
UNASSIGNED: Thirty questions were prepared after evidence-based search and reviewed by experts for suggestions. Changes were done and the questionnaire with the grading sheet was sent to 19 experts. The responses were analysed to calculate the content validity index (CVI) item-wise (I-CVI), scale-wise (S-CVI), and modified kappa statistics. The I-CVI of 0.78 and an S-CVI/average of 0.90 was taken as acceptable with more than six experts.
UNASSIGNED: Fourteen experts out of 19 assessed and graded the questions as per the provided sheet and submitted suggestions through the mail. Question reframing, option reconsideration, and change from single to multiple choices were incorporated as per the suggestions of the experts. Mean I-CVI for relevance, simplicity, clarity, and ambiguity was 0.99, 0.98, 0.98, and 0.99, respectively. S-CVI/average was 0.98, 0.97, 0.98, and 0.99 for relevance, simplicity, clarity, and ambiguity, respectively.
UNASSIGNED: We conclude that this questionnaire has met the content validity criteria and can be used to study plexus and PNBs practices.

Peripheral nerve blocks are commonly recommended as perioperative analgesia for orthopedic procedures. We aimed to determine the prevalence of use of techniques and drugs among veterinary professionals with an interest in anesthesia. Veterinary professionals were contacted via an email (ACVA-list) and newsletter (Association of Veterinary Anesthetists) containing a link to an online survey. Surveys completed in full were used for analysis. Analysis found that peripheral nerve blocks (PNBs) and epidural analgesia techniques were the preferred techniques of 46% and 38% of individuals, respectively. Of those using PNBs, nerve stimulator techniques were most common, used by 72% of individuals. Bupivacaine was used by 71% of individuals. Adjuvants were used by 37% of respondents; most commonly an alpha-2 agonist. Severe adverse effects were reported by 11 respondents, while 49% of individuals had not witnessed any adverse effects. More experienced veterinary anesthetists (>100 blocks performed) were more likely to have seen adverse effects. In conclusion, PNBs are utilized by anesthetists for pelvic limb orthopedic surgery, with nerve stimulation being the most commonly used PNB technique. Bupivacaine was the most commonly used local anesthetic however, diversity in both the techniques and drugs used was evident among respondents.

This randomized double-blind controlled trial compared the block characteristics of three low-dose local anesthetics at different roots in an ultrasound-guided interscalene block, using thermal quantitative sensory testing for assessing the functioning of cutaneous small nerve fibres. A total of 37 adults scheduled to undergo shoulder arthroscopy were randomized to receive 5 mL of either 0.5% levobupivacaine with and without epinephrine 1/200,000 or 0.75% ropivacaine in a single-shot interscalene block. Thermal quantitative sensory testing was performed in the C4, C5, C6 and C7 dermatomes. Detection thresholds for cold/warm sensation and cold/heat pain were measured before and at 30 min, 6, 10 and 24 h after infiltration around C5. The need for rescue medication was recorded. No significant differences between groups were found for any sensation (lowest P = 0.28). At 6 h, the largest differences in sensory thresholds were observed for the C5 dermatome. The increase in thresholds were less in C4 and C6 and minimal in C7 for all sensations. The analgesic effect lasted the longest in C5 (time × location mixed model P < 0.001 for all sensory tests). The time to rescue analgesia was significantly shorter with 0.75% ropivacaine (P = 0.02). The quantitative sensory findings showed no difference in intensity between the local anesthetics tested. A decrease in block intensity, with minimal changes in pain detection thresholds, was observed in the roots adjacent to C5, with the lowest block intensity in C7. A clinically relevant shorter duration was found with 0.75% ropivacaine compared to the other groups. Trial registration NCT 02691442.

This study evaluated the incidence of nerve puncture and intraneural injection based on the needle approach to the nerve (direct vs. tangential). Two expert operators in regional anaesthesia performed in-plane ultrasound-guided nerve blocks (n = 158) at different levels of the brachial plexus in cadavers, aiming either directly for the nerve (n = 77) or tangentially inferior to the nerve (n = 81). After reaching the outer limit of the nerve, the needle was intentionally advanced approximately 1 mm in both approaches, and 0.2-0.5 ml of saline was injected. Each operator classified (in real time) the needle tip and injectate as intraneural or not. Video clips showing the final position of the needle and the injection were evaluated in the same manner by seven independent expert observers who were blinded to the aims of this study. In addition, 20 injections were performed with ink for histological evaluation. Intraneural injections of saline were observed by the operator in 58% (45/77) of cases using the direct approach and 12% (10/81) of cases using the tangential approach (p < 0.001). The independent observers agreed with the operator in a substantial number of cases (Cohen\'s kappa index 0.65). Histological studies showed intraneural spread in 83% (5/6) of cases using the direct approach and in 14% (2/14) of cases using the tangential approach (p = 0.007). No intrafascicular injections were observed. There was good agreement between the operators\' assessment and subsequent histological evaluation (Cohen\'s kappa = 0.89). Simulation of an unintentional/accidental advancement of the needle \'beyond the edge\' of the nerve suggests significantly increased risk of epineural perforation and intraneural injection when a direct approach to the nerve is used, compared with a tangential approach.

OBJECTIVE: The objective of this study is to provide demographical and clinical descriptions of patients age 65 years old and older who were treated with peripheral nerve blocks (PNBs) at our institution and evaluate the safety and efficacy of this treatment.
BACKGROUND: Headache disorders are common, disabling chronic neurological diseases that often persist with advancing age. Geriatric headache management poses unique therapeutic challenges because of considerations of comorbidity, drug interactions, and adverse effects. Peripheral nerve blocks are commonly used for acute and short-term prophylactic treatment for headache disorders and may be a safer alternative to standard pharmacotherapy in this demographic.
METHODS: We performed a single center, retrospective chart review of patients at least 65 years of age who received peripheral nerve blocks for headache management over a 6 year period.
RESULTS: Sixty-four patients were mostly female (78%) with an average age of 71 years (range 65-94). Representative headache diagnoses were chronic migraine 50%, episodic migraine 12.5%, trigeminal autonomic cephalalgia 9.4%, and occipital neuralgia 7.8%. Average number of headache days/month was 23. Common comorbidities were hypertension 48%, hyperlipidemia 42%, arthritis 27%, depression 47%, and anxiety 33%. Eighty-nine percent were prescribed at least 1 medication fulfilling the Beers criteria. The average number of peripheral nerve blocks per patient was 4. Peripheral nerve blocks were felt to be effective in 73% for all headaches, 81% for chronic migraine, 75% for episodic migraine, 67% for chronic tension type headache, 67% for new daily persistent headache, and 60% for occipital neuralgia. There were no adverse events related to PNBs reported.
CONCLUSIONS: PNBs might be a safe and effective alternative headache management strategy for older adults. Medical and psychiatric comorbidities, medication overuse, and Beers list medication rates were extraordinarily high, giving credence to the use of peripherally administered therapies in the geriatric population that may be better tolerated and safer.