Interscalene brachial plexus block.
TL;DR: It is shown that by depositing a few milliliters of anesthetic solution into this sheath on either side of the artery at the level of insertion of the great adductors of the arm, the surgeon was able to obtain excellent anesthesia in the majority of the few cases he reported.
Abstract: EN YEARS ago, an orthopedic surgeon, T Burnham1j2 first reported on the concept of perivascular anesthesia of the brachial plexus as we conceive of it today. During surgery for a deep laceration of the apex of the axilla (fig. l), he observed the compact arrangement of the nerves around the artery and the manner in which they were enveloped by a fascia1 “sheath,” and was impressed by the potential efficacy of a block performed at this level. Subsequently, by depositing a few milliliters of anesthetic solution into this sheath on either side of the artery at the level of insertion of the great adductors of the arm, he was able to obtain excellent anesthesia in the majority of the few cases he reported.
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TL;DR: The reader is introduced to the theory and practice of ultrasound-guided anaesthetic techniques in adults and children and considers their enormous potential to have a role in the future training of anaesthetists.
Abstract: The technology and clinical understanding of anatomical sonography has evolved greatly over the past decade. In the Department of Anaesthesia and Intensive Care Medicine at the Medical University of Vienna, ultrasonography has become a routine technique for regional anaesthetic nerve block. Recent studies have shown that direct visualization of the distribution of local anaesthetics with high-frequency probes can improve the quality and avoid the complications of upper/lower extremity nerve blocks and neuroaxial techniques. Ultrasound guidance enables the anaesthetist to secure an accurate needle position and to monitor the distribution of the local anaesthetic in real time. The advantages over conventional guidance techniques, such as nerve stimulation and loss-of-resistance procedures, are significant. This review introduces the reader to the theory and practice of ultrasound-guided anaesthetic techniques in adults and children. Considering their enormous potential, these techniques should have a role in the future training of anaesthetists.
618 citations
TL;DR: Good radiological results were achieved in 4-part fractures when impacted in valgus except for one patient with partial av vascular necrosis of the head, and revision to a prosthesis was required in one patient because of avascular necrosis and in another because of secondary redisplacement of the fracture.
Abstract: Untreated 3- and 4-part fractures of the proximal humerus have a poor functional outcome. Open operation increases the risk of avascular necrosis and percutaneous reduction and fixation may be preferable. We report 27 patients, 9 with 3-part and 18 with 4-part fractures, treated by percutaneous reduction and screw fixation. Thirteen of the 4-part fractures were of the valgus type with no significant lateral displacement of the articular segment, and five showed significant shift. Instruments were introduced into the fracture through small incisions so that the fragments could be manoeuvred under the control of an image intensifier, taking advantage of ligamentotaxis as far as possible. A good reduction was achieved in most cases. The average follow-up was 24 months (18 to 47). All the 3-part fractures showed good to very good functional results, with an average Constant score of 91% (84% to 100%), and no signs of avascular necrosis. Good radiological results were achieved in 4-part fractures when impacted in valgus except for one patient with partial avascular necrosis of the head. In those with lateral displacement of the head, revision to a prosthesis was required in one patient because of avascular necrosis and in another because of secondary redisplacement of the fracture. Avascular necrosis was seen in 11% of 4-part fractures. The average Constant score in patients with 4-part fractures who did not need further operation was 87% (75% to 100%).
392 citations
TL;DR: This study demonstrated that regional anesthesia has several benefits over general anesthesia for this type of surgery, particularly in the ambulatory patient, and was found to be safe and effective, with a high degree of patient acceptance.
Abstract: Arthroscopic shoulder surgery can be performed under regional or general anesthesia. The objective of this study was to demonstrate that regional anesthesia has several benefits over general anesthesia for this type of surgery, particularly in the ambulatory patient. Forty patients received general anesthesia and 63 an interscalene block. The regional block was found to be safe and effective, with a high degree of patient acceptance. It provided excellent intraoperative analgesia and muscle relaxation. Postoperatively, regional anesthesia resulted in fewer side effects, fewer hospital admissions, and a shorter hospital stay than did general anesthesia.
305 citations
TL;DR: The combined effect of dexamethasone and either drug produced nearly the same 22 h of analgesia, with the effect being stronger with ropivacaine.
Abstract: Background Pain after shoulder surgery is often treated with interscalene nerve blocks. Single-injection blocks are effective, but time-limited. Adjuncts such as dexamethasone may help. We thus tested the hypothesis that adding dexamethasone significantly prolongs the duration of ropivacaine and bupivacaine analgesia and that the magnitude of the effect differs among the two local anaesthetics. Methods In a double-blinded trial utilizing single-injection interscalene block, patients were randomized to one of four groups: (i) ropivacaine: 0.5% ropivacaine; (ii) bupivacaine: 0.5% bupivacaine; (iii) ropivacaine and steroid: 0.5% ropivacaine mixed with dexamethasone 8 mg; and (iv) bupivacaine and steroid: 0.5% bupivacaine mixed with dexamethasone 8 mg. The primary outcome was time to first analgesic request after post-anaesthesia care unit discharge. The Kaplan–Meier survival density estimation and stratified Cox's proportional hazard regression were used to compare groups. Results Dexamethasone significantly prolonged the duration of analgesia of both ropivacaine [median (inter-quartile range) 11.8 (9.7, 13.8) vs 22.2 (18.0, 28.6) h, log-rank P Conclusions Dexamethasone prolongs analgesia from interscalene blocks using ropivacaine or bupivacaine, with the effect being stronger with ropivacaine. However, block duration was longer with plain bupivacaine than ropivacaine. Thus, although dexamethasone prolonged the action of ropivacaine more than that of bupivacaine, the combined effect of dexamethasone and either drug produced nearly the same 22 h of analgesia.
290 citations
TL;DR: Assessment of the evidence relating to the effectiveness of regional anaesthesia techniques commonly used for postoperative analgesia following shoulder surgery finds continuous interscalene block incorporating a basal local anaesthetic infusion and patient controlled boluses is the most effective analgesic technique following both major and minor shoulder surgery.
Abstract: Shoulder surgery is well recognised as having the potential to cause severe postoperative pain. The aim of this review is to assess critically the evidence relating to the effectiveness of regional anaesthesia techniques commonly used for postoperative analgesia following shoulder surgery. Subacromial/intra-articular local anaesthetic infiltration appears to perform only marginally better than placebo, and because the technique has been associated with catastrophic chondrolysis, it can no longer be recommended. All single injection nerve blocks are limited by a short effective duration. Suprascapular nerve block reduces postoperative pain and opioid consumption following arthroscopic surgery, but provides inferior analgesia compared with single injection interscalene block. Continuous interscalene block incorporating a basal local anaesthetic infusion and patient controlled boluses is the most effective analgesic technique following both major and minor shoulder surgery. However, interscalene nerve block is an invasive procedure with potentially serious complications and should therefore only be performed by practitioners with appropriate experience.
288 citations
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TL;DR: The authors have developed the subclavian perivascular technique which affords greater simplicity) safety and consistency of results than presently used supraclavicular technique.
Abstract: The prevertebral fascia envelops the brachial plexus from the cervical vertebrae to the distal axilla, forming a subclavian perivascular space that is continuous with the axillary perivascular space. By applying the concept of the axillary perivascular technique to the supraclavicular approach, the
228 citations
TL;DR: The axillary approach to brachial plexus block is rapidly gaining in popularity in North America, having almost replaced the supraclavicular approach in some centres and the method would appear to deserve wider recognition.
Abstract: The axillary approach to brachial plexus block is rapidly gaining in popularity in North America, having almost replaced the supraclavicular approach in some centres and the method would appear to deserve wider recognition. Axillary block offers several advantages over the supraclavicular technique of brachial plexus block and has no serious disadvantages. The principal advantage of the axillary approach is the complete avoidance of the complication of pneumothorax, while offering at least an equal chance of successful block. When bilateral blocks are to be performed, the axillary technique is particularly suitable as it avoids the doubled risk of inducing pneumothorax and phrenic nerve paralysis which exists if the supraclavicular method is used. The value of brachial plexus block for the patient with a full stomach, for the outpatient, for the diabetic, for the patient with cardiac, pulmonary, hepatic or renal disease and for the tough anaesthetic-resistant adult is recognised. Only the risk of inducing a pneumothorax may have deterred anaesthetists from employing an otherwise excellent technique for such patients. Brachial plexus block is associated with little or no post-operative nausea and vomiting. It is an economical technique, requires the minimum of equipment and is suitable for use in disaster conditions.
66 citations
65 citations
TL;DR: Injuries to the hand and forearm consistently hold a high place in the incidence of bodily trauma and the local use of anesthetic agents throughout the field of trauma is to be decried for many reasons, among which are the spreading of infection in an open wound.
Abstract: Injuries to the hand and forearm consistently hold a high place in the incidence of bodily trauma They often need to be repaired immediately Unfortunately, the stomach is often full of food and drink or there are multiple injuries which make the use of a general anesthetic a dangerous procedure The supraclavicular brachial plexus block has often been employed However, this block has many disadvantages: First, it is accomplished by pneumothorax and/or phrenic nerve paralysis in 2 to 25% of cases reported 1 Such a complication might well prove overwhelming to the patient with a severe chest injury Second, the block is effective in only 68 to 90% of cases 2 Consequently, general anesthesia is often reluctantly used to augment this block The local use of anesthetic agents throughout the field of trauma is to be decried for many reasons, among which are the spreading of infection in an open wound,
50 citations