BackgroundAnatomical knowledge dictates that regional anaesthesia after total hip arthroplasty requires blockade of the hip articular branches of the femoral and obturator nerves. A direct femoral nerve block increases the risk of fall and impedes mobilisation. We propose a selective nerve block of the hip articular branches of the femoral nerve by an ultrasound‐guided injection in the plane between the iliopsoas muscle and the iliofemoral ligament (the iliopsoas plane). The aim of this study was to assess whether dye injected in the iliopsoas plane spreads to all hip articular branches of the femoral nerve.MethodsFifteen cadaver sides were injected with 5 mL dye in the iliopsoas plane guided by ultrasound. Dissection was performed to verify the spread of injectate around the hip articular branches of the femoral nerve.ResultsIn 10 dissections (67% [95% confidence interval: 38‐88%]), the injectate was contained in the iliopsoas plane staining all hip articular branches of the femoral nerve without spread to motor branches. In four dissections (27% [8‐55%]), the injection was unintentionally made within the iliopectineal bursa resulting in secondary spread. In one dissection (7% [0.2‐32%]) adhesions partially obstructed the spread of dye.ConclusionAn injection of 5 mL in the iliopsoas plane spreads around all hip articular branches of the femoral nerve in 10 of 15 cadaver sides. If these findings translate to living humans, injection of local anaesthetic into the iliopsoas plane could generate a selective sensory nerve block of the articular branches of the femoral nerve without motor blockade.

Hintergrund: Während mehrere Studien Vorteile für minimal invasive Operationstechniken gegenüber offener Methoden bezüglich der Morbidität zeigen, ist die ontologische Qualität ersterer in Diskussion. Als Optimum der Lymphadenektomie (LA) werden mindestens 23 entfernte und untersuchte Lymphknoten gefordert; für ein adäquates TNM Staging zumindest 15. In mindestens 90% ist eine R-0 Resektion gefordert. Wir berichten über die Qualität der 2-Feld-Lymphadenektomie und Radikalität der abdominothorakalen Ösophagusresektion in Hybridtechnik (HIL) seit Etablierung unseres Speiseröhrenzentrums Ende 2013. Methode: 2014/2015 wurden 45 Patienten einer Ösophagusresektion unterzogen (38 mit ÖCA, 7 mit anderer Indikation: Leiomyom 1, langstreckige Barrett Dysplasie 1, Perforation 1, end stage Achalasie 1, therapierefraktäre Stenose 3). Bei 27 Patienten wurde eine HIL mit 2-Feldlymphadenektomie durchgeführt. Die abdominelle LA wurde laparoskopisch durchgeführt und beinhaltete die Stationen 1 – 3, 7 – 9 und 11 und die transhiatale enbloc Mobilisierung des distalen Ösophagus. Die mediastinale LA erfolgte über eine rechtsseitige muskelschonende anterolaterale Thorakotomie unter Single-lung-Ventilation und inkludierte den D. thoracicus, die mediastinalen Blätter der Pleura sowie die periösophagealen, infracarinalen und paratrachealen NLL. Die V. azygos blieb erhalten. Als Surrogatparameter für die Qualität der LA wurde die Anzahl der entfernten NLLL und der Anteil an Patienten mit einer NLL-Zahl > 23 ermittelt. Ergebnisse: Die mediale Anzahl entfernter NLL war 31 (11 – 47). Bei 23/27 (85,2%) Patienten lag die NLL Zahl über 23. Die R-0 Rate war 96,3%. Diskussion: Mit der HIL mit 2-Feldlymphadenektomie war in unseren Händen eine im Vergleich mit internationalen Daten sehr hohe mediale Anzahl an entfernten und untersuchten NLL erreichbar. Bei 85% war die onkologisch ideale NLL-Anzahl von über 23 erreichbar, lediglich in einem Fall waren trotz regulärer morphologischer LA die für exaktes N-Staging geforderten 15 NLL nicht erreicht. Die R-0 Rate war mit weit über 90% im internationalen Vergleich sehr hoch, obwohl die meisten Patienten an fortgeschrittenen Karzinomen litten.

BACKGROUND Local anaesthetic blocks of the greater occipital nerve (GON) are frequently performed in different types of headache, but no selective approaches exist. Our cadaver study compares the sonographic visibility of the nerve and the accuracy and specificity of ultrasound-guided injections at two different sites. METHODS After sonographic measurements in 10 embalmed cadavers, 20 ultrasound-guided injections of the GON were performed with 0.1 ml of dye at the classical site (superior nuchal line) followed by 20 at a newly described site more proximal (C2, superficial to the obliquus capitis inferior muscle). The spread of dye and coloration of nerve were evaluated by dissection. RESULTS The median sonographic diameter of the GON was 4.2 x 1.4 mm at the classical and 4.0 x 1.8 mm at the new site. The nerves were found at a median depth of 8 and 17.5 mm, respectively. In 16 of 20 in the classical approach and 20 of 20 in the new approach, the nerve was successfully coloured with the dye. This corresponds to a block success rate of 80% (95% confidence interval: 58-93%) vs 100% (95% confidence interval: 86-100%), which is statistically significant (McNemar's test, P=0.002). CONCLUSIONS Our findings confirm that the GON can be visualized using ultrasound both at the level of the superior nuchal line and C2. This newly described approach superficial to the obliquus capitis inferior muscle has a higher success rate and should allow a more precise blockade of the nerve.

European Journal of PainVolume 10, Issue S1 p. S151-S151 573 ULTRASOUND-GUIDED BLOCK OF THE GREATER OCCIPITAL NERVE: ACCURACY OF A SELECTIVE NEW TECHNIQUE CONFIRMED BY ANATOMICAL DISSECTION U. Eichenberger, U. Eichenberger Department of Anaesthesiology, University Hospital of Bern, Inselspital, Bern, SwitzerlandSearch for more papers by this authorM. Greher, M. Greher Department of Anaesthesia, Herz-Jesu KrankenhausSearch for more papers by this authorM. Curatolo, M. Curatolo Department of Anaesthesiology, University Hospital of Bern, Inselspital, Bern, SwitzerlandSearch for more papers by this authorL. Kirchmair, L. Kirchmair Department of Anaesthesia and Intensive Care Innsbruck Medical University, InnsbruckSearch for more papers by this authorB. Moriggl, B. Moriggl Department of Anatomy, Histology and Embryology, Innsbruck Medical University, Innsbruck, AustriaSearch for more papers by this author U. Eichenberger, U. Eichenberger Department of Anaesthesiology, University Hospital of Bern, Inselspital, Bern, SwitzerlandSearch for more papers by this authorM. Greher, M. Greher Department of Anaesthesia, Herz-Jesu KrankenhausSearch for more papers by this authorM. Curatolo, M. Curatolo Department of Anaesthesiology, University Hospital of Bern, Inselspital, Bern, SwitzerlandSearch for more papers by this authorL. Kirchmair, L. Kirchmair Department of Anaesthesia and Intensive Care Innsbruck Medical University, InnsbruckSearch for more papers by this authorB. Moriggl, B. Moriggl Department of Anatomy, Histology and Embryology, Innsbruck Medical University, Innsbruck, AustriaSearch for more papers by this author First published: 13 January 2012 https://doi.org/10.1016/S1090-3801(06)60576-4Read the full textAboutPDF ToolsRequest permissionExport citationAdd to favoritesTrack citation ShareShare Give accessShare full text accessShare full-text accessPlease review our Terms and Conditions of Use and check box below to share full-text version of article.I have read and accept the Wiley Online Library Terms and Conditions of UseShareable LinkUse the link below to share a full-text version of this article with your friends and colleagues. Learn more.Copy URL Share a linkShare onFacebookTwitterLinkedInRedditWechat No abstract is available for this article. Volume10, IssueS1September 2006Pages S151-S151 RelatedInformation

Background. Ilioinguinal and iliohypogastric nerve blocks may be used in the diagnosis of chronic groin pain or for analgesia for hernia repair. This study describes a new ultrasound-guided approach to these nerves and determines its accuracy using anatomical dissection control.Methods. After having tested the new method in a pilot cadaver, 10 additional embalmed cadavers were used to perform 37 ultrasound-guided blocks of the ilioinguinal and iliohypogastric nerve. After injection of 0.1 ml of dye the cadavers were dissected to evaluate needle position and colouring of the nerves.Results. Thirty-three of the thirty-seven needle tips were located at the exact target point, in or directly at the ilioinguinal or iliohypogastric nerve. In all these cases the targeted nerve was coloured entirely. In two of the remaining four cases parts of the nerves were coloured. This corresponds to a simulated block success rate of 95%. In contrast to the standard 'blind' techniques of inguinal nerve blocks we visualized and targeted the nerves 5 cm cranial and posterior to the anterior superior iliac spine. The median diameters of the nerves measured by ultrasound were: ilioinguinal 3.0x1.6 mm, and iliohypogastric 2.9x1.6 mm. The median distance of the ilioinguinal nerve to the iliac bone was 6.0 mm and the distance between the two nerves was 10.4 mm.Conclusions. The anatomical dissections confirmed that our new ultrasound-guided approach to the ilioinguinal and iliohypogastric nerve is accurate. Ultrasound could become an attractive alternative to the 'blind' standard techniques of ilioinguinal and iliohypogastric nerve block in pain medicine and anaesthetic practice.

BACKGROUND:Chronic neck pain after whiplash injury is caused by cervical zygapophysial joints in 50% of patients. Diagnostic blocks of nerves supplying the joints are performed using fluoroscopy. The authors' hypothesis was that the third occipital nerve can be visualized and blocked with use of an ultrasound-guided technique.METHODS:In 14 volunteers, the authors placed a needle ultrasound-guided to the third occipital nerve on both sides of the neck. They punctured caudal and perpendicular to the 14-MHz transducer. In 11 volunteers, 0.9 ml of either local anesthetic or normal saline was applied in a randomized, double-blind, crossover manner. Anesthesia was controlled in the corresponding skin area by pinprick and cold testing. The position of the needle was controlled by fluoroscopy.RESULTS:The third occipital nerve could be visualized in all subjects and showed a median diameter of 2.0 mm. Anesthesia was missing after local anesthetic in only one case. There was neither anesthesia nor hyposensitivity after any of the saline injections. The C2-C3 joint, in a transversal plane visualized as a convex density, was identified correctly by ultrasound in 27 of 28 cases, and 23 needles were placed correctly into the target zone.CONCLUSIONS:The third occipital nerve can be visualized and blocked with use of an ultrasound-guided technique. The needles were positioned accurately in 82% of cases as confirmed by fluoroscopy; the nerve was blocked in 90% of cases. Because ultrasound is the only available technique today to visualize this nerve, it seems to be a promising new method for block guidance instead of fluoroscopy.

Greher, M.; Tagwerker, B.; Eichenberger, U.; Marhofer, P.; Kapral, S. Author Information

BACKGROUND:Lumbar facet nerve (medial branch) block for pain relief in facet syndrome is currently performed under fluoroscopic or computed tomography scan guidance. In this three-part study, the authors developed a new ultrasound-guided methodology, described the necessary landmarks and views, assessed ultrasound-derived distances, and tested the clinical feasibility.METHODS:(1) A paravertebral cross-axis view and long-axis view were defined under high-resolution ultrasound (15 MHz). Three needles were guided to the target point at L3-L5 in a fresh, nonembalmed cadaver under ultrasound (2-6 MHz) and were subsequently traced by means of dissection. (2) The lumbar regions of 20 volunteers (9 women, 11 men; median age, 36 yr [23-67 yr]; median body mass index, 23 kg/m2 [19-36 kg/m2]) were studied with ultrasound (3.5 MHz) to assess visibility of landmarks and relevant distances at L3-L5 in a total of 240 views. (3) Twenty-eight ultrasound-guided blocks were performed in five patients (two women, three men; median age, 51 yr [31-68 yr]) and controlled under fluoroscopy.RESULTS:In the cadaver, needle positions were correct as revealed by dissection at all three levels. In the volunteers, ultrasound landmarks were delineated as good in 19 and of sufficient quality in one (body mass index, 36 kg/m2). Skin-target distances increased from L3 to L5, reaching statistical significance (*, **P < 0.05) between these levels on both sides: L3r, 45+/-6 mm*; L4r, 48+/-7 mm; L5r, 50+/-6 mm*; L3l, 44+/-5 mm**; L4l, 47+/-6 mm; L5l, 50+/-6 mm**. In patients, 25 of 28 ultrasound-guided needles were placed accurately, with the remaining three closer than 5 mm to the radiologically defined target point.CONCLUSION:Ultrasound guidance seems to be a promising new technique with clinical relevance and the potential to increase practicability while avoiding radiation in lumbar facet nerve block.

Patients with trauma or medical illnesses transported to the hospital by ambulance have a frequent incidence of motion sickness. Because the administration of drugs in the ambulance is prohibited by law in Austria, the non-invasive Korean hand acupressure point at K-K9 may be an alternative against nausea and vomiting. We enrolled 100 geriatric patients with minor trauma, randomizing them into a K-K9 group and a sham acupressure group. We recorded visual analog scores (VAS) for nausea and for the patient's overall satisfaction with the treatment, hemodynamic variables, and peripheral vasoconstriction. In the K-K9 group, a significant (P < 0.01) increase in nausea was recorded in all cases: from VAS of 0 mm to 25 +/- 6 mm. A similarly significant (P < 0.01) increase was registered in the sham group: from VAS of 0 mm to 83 +/- 8 ram. However, at the time of arrival in the hospital, nausea scores were significantly different between the K-K9 group and the sham group (P < 0.01). Although all patients had been vasoconstricted at the emergency site before treatment, there was a significant difference (P < 0.01) between groups with regard to the number of vasoconstricted patients at the hospital (4 and 46 constricted and dilated, respectively, in the K-K9 group versus 48 and 2 constricted and dilated, respectively, in the sham group). On arrival in the hospital, a significant difference (P < 0.01) in heart rate was noted between the K-K9 group and the sham group (65 +/- 6 bpm versus 98 +/- 8 bpm). The patients' overall satisfaction with the provided care was significantly higher (P < 0.01) in the K-K9 group (19 +/- 9 mm VAS) than in the sham group (48 +/- 12 mm VAS). Neither group experienced a significant change in blood pressure. K-K9 stimulation was an effective and simple treatment for nausea during emergency care and significantly improved patient satisfaction.

Ultrasonography may offer significant advantages in regional anaesthesia of the upper and lower limbs. It is not known if the same advantages demonstrated in adults also apply to children. We therefore performed a prospective, randomised study comparing ultrasound visualisation to conventional nerve stimulation for infraclavicular brachial plexus anasesthesia in children. Forty children scheduled for arm and forearm surgery underwent infraclavicular brachial plexus blocks with ropivacaine 0.5 ml.kg −1 guided by either nerve stimulation or ultrasound visualisation. Evaluated parameters included sensory block quality, sensory block distribution and motor block. All surgical procedures were performed under brachial plexus anaesthesia alone. Direct ultrasound visualisation was successful in all cases and was associated with significant improvements when compared with the use of nerve stimulation: lower visual analogue scores during puncture ( p  = 0.03), shorter mean (median) sensory onset times (9 (5–15) min vs. 15 (5–25) min, p < 0.001), longer sensory block durations (384 (280–480) min vs. 310 (210–420) min, p < 0.001), and better sensory and motor block scores 10 min afrter block insertion. Ultrasound visualisation offers faster sensory and motor responses and a longer duration of sensory blockade than nerve stimulation in children undergoing infraclavicular brachial plexus blocks. In addition, the pain associated with nerve stimulation due to muscle contractions at the time of insertion is eliminated.

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.

Background: Lumbar facet nerve (medial branch) blocks are often used to diagnose facet joint-mediated pain. The authors recently described a new ultrasound-guided methodology. The current study determines its accuracy using computed tomography scan controls.Methods: Fifty bilateral ultrasound-guided approaches to the lumbar facet nerves were performed in five embalmed cadavers. The target point was the groove at the cephalad margin of the transverse (or costal) process L1-L5 (medial branch T12-L4) adjacent to the superior articular process. Axial transverse computed tomography scans, with and without 1 ml contrast dye, followed to evaluate needle positions and spread of contrast medium.Results: Forty-five of 50 needle tips were located at the exact target point. The remaining 5 were within 5 mm of the target. In 47 of 50 cases, the applied contrast dye reached the groove where the nerve is located, corresponding to a simulated block success rate of 94% (95% confidence interval, 84-98%). Seven of 50 cases showed paraforaminal spread, 5 of 50 showed epidural spread, and 2 of 50 showed intravascular spread. Despite the aberrant distribution, all of these approaches were successful, as indicated by contrast dye at the target point. Abnormal contrast spread was equally distributed among all lumbar levels. Contrast traces along the needle channels were frequently observed.Conclusions: The computed tomography scans confirm that our ultrasound technique for lumbar facet nerve block is highly accurate for the target at all five lumbar transverse processes (medial branches T12-L4). Aberrant contrast medium spread is comparable to that of the classic fluoroscopy-guided method.

Greher, M.; Kirchmair, L.; Enna, B.; Kovacs, P.; Gustorff, B.; Kapral, S.; Moriggl, B. Author Information

BACKGROUND:Pediatric regional anesthesia has gained increasing interest over the past decades. The current study was conducted to investigate the lumbar paravertebral region and the lumbar plexus at L3-L4 and L4-L5 by means of sonography to obtain fundamentals for the performance of ultrasound-guided posterior lumbar plexus blocks. METHODS:Thirty-two children (12 boys, 20 girls) with American Society of Anesthesiologists physical status I or II were enrolled in the current study. The lumbar paravertebral region was visualized at L3-L4 and L4-L5 on two corresponding posterior sonograms (longitudinal, transverse). The lumbar plexus had to be delineated, and skin-plexus distances were measured. In a series of five pediatric patients undergoing inguinal herniotomy, ultrasound-guided posterior lumbar plexus blocks at L4-L5 were performed. RESULTS:The children were stratified into three age groups (group 1: > 3 yr and = 5 yr; group 2: > 5 yr and = 8 yr; group 3: > 8 yr and = 12 yr). The lumbar plexus could be delineated at L3-L4 and L4-L5 in 19 of 20 cases in group 1, in 17 of 20 cases in group 2, in 22 of 24 cases at L3-L4 in group 3, and in 16 of 24 cases at L4-L5 in group 3. In all patients, the lumbar plexus was situated within the posterior part of the psoas major muscle. Skin-plexus distances showed statistical significant differences between groups 1 and 3 and between groups 2 and 3. The strongest positive correlation existed between skin-plexus distances and the children's weight. Ultrasound guidance enabled safe und successful posterior approaches to the lumbar plexus, thus resulting in effective anesthesia and analgesia of the inguinal region. CONCLUSIONS:Sonography of the lumbar plexus in children proved to be feasible. Skin-plexus distances correlated with the children's weight rather than with their age. The sonographic findings were fundamental for the performance of successful ultrasound-guided posterior approaches in a small group of pediatric patients.

BACKGROUND:Brachial plexus blockade is a well-established technique in upper-limb surgery. In paediatric patients, the axillary route is usually preferred to infraclavicular approaches because of safety considerations. Recent reports on a lateral infraclavicular approach offering greater safety in adults prompted us to perform a prospective randomized study to assess the analgesic efficacy of axillary vs lateral vertical infraclavicular brachial plexus (LVIBP) blocks in paediatric trauma surgery.METHODS:Forty paediatric trauma patients (ASA physical status I and II, age range 1-10 years) scheduled for forearm or hand surgery were randomly assigned to either axillary brachial plexus (ABP group) or LVIBP group blocks using 0.5 ml.kg(-1) ropivacaine 0.5%. Sensory blockade was evaluated by a visual analogue score and Vester-Andersen's criteria, the distribution of sensory and motor blockade was evaluated by a simplified pinprick test and motor tests.RESULTS:In the LVIBP group, Vester-Andersen's criteria were met by 100% of children, compared with 80% in the ABP group (P=0.035). Based on all assessable children, sensory blockade in the primary sensory regions of various nerves was significantly more effective in the LVIBP group (axillary: P < 0.0001; musculocutaneous: P=0.002; medial brachial cutaneous; P=0.008). Motor blockade was also significantly more effective (axillary: P < 0.0001; musculocutaneous: P=0.003). No major complications were observed in either group.DISCUSSION:We conclude that LVIBP blocks can be safely performed in children and that they add to the spectrum of sensory and motor blockade seen with the axillary approach.