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Pérez-Montalbán M, García-Domínguez E, Oliva-Pascual-Vaca Á. Subdiaphragmatic phrenic nerve supply: A systematic review. Ann Anat 2024; 254:152269. [PMID: 38692333 DOI: 10.1016/j.aanat.2024.152269] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/05/2024] [Revised: 04/18/2024] [Accepted: 04/23/2024] [Indexed: 05/03/2024]
Abstract
OBJECTIVE The aim of this systematic review is to study the subdiaphragmatic anatomy of the phrenic nerve. MATERIALS AND METHODS A computerised systematic search of the Web of Science database was conducted. The key terms used were phrenic nerve, subdiaphragmat*, esophag*, liver, stomach, pancre*, duoden*, intestin*, bowel, gangli*, biliar*, Oddi, gallbladder, peritone*, spleen, splenic, hepat*, Glisson, falciform, coronary ligament, kidney, suprarenal, and adrenal. The 'cited-by' articles were also reviewed to ensure that all appropriate studies were included. RESULTS A total of one thousand three hundred and thirty articles were found, of which eighteen met the inclusion and exclusion criteria. The Quality Appraisal for Cadaveric Studies scale revealed substantial to excellent methodological quality of human studies, while a modified version of the Systematic Review Centre for Laboratory Animal Experimentation Risk of Bias Tool denoted poor methodological quality of animal studies. According to human studies, phrenic supply has been demonstrated for the gastro-esophageal junction, stomach, celiac ganglia, liver and its coronary ligament, inferior vena cava, gallbladder and adrenal glands, with half of the human samples studied presenting phrenic nerve connections with any subdiaphragmatic structure. CONCLUSIONS This review provides the first systematic evidence of subdiaphragmatic phrenic nerve supply and connections. This is of interest to professionals who care for people suffering from neck and shoulder pain, as well as patients with peridiaphragmatic disorders or hiccups. However, there are controversies about the autonomic or sensory nature of this supply.
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Affiliation(s)
- María Pérez-Montalbán
- Universidad de Sevilla. Facultad de Enfermería, Fisioterapia y Podología, Departamento de Fisioterapia, Spain
| | | | - Ángel Oliva-Pascual-Vaca
- Instituto de Biomedicina de Sevilla, IBiS, Departamento de Fisioterapia, Universidad de Sevilla, Spain; Escuela de Osteopatía de Madrid, Madrid, Spain.
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Laucius O, Drūteika J, Balnytė R, Petrikonis K, Ališauskienė M, Vaitkus A. Sonographic Phrenic Nerve Changes in Amyotrophic Lateral Sclerosis. MEDICINA (KAUNAS, LITHUANIA) 2023; 59:1745. [PMID: 37893463 PMCID: PMC10608041 DOI: 10.3390/medicina59101745] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 08/20/2023] [Revised: 09/19/2023] [Accepted: 09/25/2023] [Indexed: 10/29/2023]
Abstract
Amyotrophic lateral sclerosis (ALS) is a progressive neurodegenerative disease that affects both the upper and lower motor neurons in the nervous system, causing muscle weakness and severe disability. The progressive course of the disease reduces the functional capacity of the affected patients, limits daily activities, and leads to complete dependence on caregivers, ultimately resulting in a fatal outcome. Respiratory dysfunction mostly occurs later in the disease and is associated with a worse prognosis. Forty-six participants were included in our study, with 23 patients in the ALS group and 23 individuals in the control group. The ultrasound examination of the phrenic nerve (PN) was performed by two authors using a high-resolution "Philips EPIQ 7" ultrasound machine with a linear 4-18 MHz transducer. Our study revealed that the phrenic nerve is significantly smaller on both sides in ALS patients compared to the control group (p < 0.001). Only one significant study on PN ultrasound in ALS, conducted in Japan, also showed significant results (p < 0.00001). These small studies are particularly promising, as they suggest that ultrasound findings could serve as an additional diagnostic tool for ALS.
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Affiliation(s)
- Ovidijus Laucius
- Department of Neurology, Medical Academy, Lithuanian University of Health Sciences, 44307 Kaunas, Lithuania
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Sripriya R, Manisha Gupta J, Arthi PR, Parthasarathy S. Ultrasound measurement of the distance of the phrenic nerve from the brachial plexus at the classic interscalene point and upper trunk: A volunteer-based observational study. Indian J Anaesth 2023; 67:457-462. [PMID: 37333704 PMCID: PMC10269976 DOI: 10.4103/ija.ija_1052_22] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/27/2022] [Revised: 03/30/2023] [Accepted: 03/30/2023] [Indexed: 06/20/2023] Open
Abstract
Background and Aims The method of blocking the brachial plexus at the level of the upper trunk has been gaining popularity as a phrenic nerve-sparing alternative for interscalene block. We aimed to measure the distance of the phrenic nerve from the upper trunk and compare it with the distance between the phrenic nerve and the brachial plexus at the classic interscalene point by using ultrasound. Method In this study, after ethical approval and trial registration, 100 brachial plexus of 50 volunteers were scanned from the emergence of the ventral rami and its course was traced to the supraclavicular fossa. The distance of the phrenic nerve from the brachial plexus was measured at two levels: the interscalene groove along the cricoid cartilage (classic interscalene block point) and from the upper trunk. The presence of anatomical variations of the brachial plexus, the classic traffic light sign, vessels across the plexus, and the location of the cervical oesophagus were also noted. Results At the classic interscalene point, the C5 ventral ramus was observed to be just emerging or to have fully emerged from the transverse process. The phrenic nerve was identified in 86/100 (86%) of scans. The median (IQR) distance of the phrenic nerve from the C5 ventral ramus was 1.6 (1.1-3.9) mm and that of the phrenic nerve from the upper trunk was 17 (12-20.5) mm. Anatomical variations of the brachial plexus, the classic traffic light sign, and vessels across the plexus were seen in 27/100, 53/100, and 41/100 scans respectively. The oesophagus was consistently located on the left side of the trachea. Conclusions There was a 10-fold increase in the distance of the phrenic nerve from the upper trunk when compared to that from the brachial plexus at the classic interscalene point.
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Affiliation(s)
- R Sripriya
- Department of Anaesthesiology, AIIMS, Mangalagiri, Andhra Pradesh, India
| | - J Manisha Gupta
- Department of Anaesthesiology, Mahatma Gandhi Medical College and Research Institute, Sri Balaji Vidyapeeth (Deemed to be university), Puducherry, India
| | - P R Arthi
- Department of Anaesthesiology, Mahatma Gandhi Medical College and Research Institute, Sri Balaji Vidyapeeth (Deemed to be university), Puducherry, India
| | - S Parthasarathy
- Department of Anaesthesiology, Mahatma Gandhi Medical College and Research Institute, Sri Balaji Vidyapeeth (Deemed to be university), Puducherry, India
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Ultrasound-Guided Phrenic Nerve Block for Lung Nodule Biopsy: Single-Center Initial Experience. Acad Radiol 2022; 29 Suppl 2:S118-S126. [PMID: 34108113 DOI: 10.1016/j.acra.2021.04.017] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/29/2020] [Revised: 04/05/2021] [Accepted: 04/13/2021] [Indexed: 11/22/2022]
Abstract
RATIONALE AND OBJECTIVES Biopsy of lung nodules in the lower lung fields can be difficult because of breathing motion. Ipsilateral phrenic nerve block (PNB) before biopsy should make the biopsy safer, easier, and more precisely targeted. We describe the use of ultrasound-guided PNB before lung nodule biopsy, including relevant anatomy and variations, complications, and technique, along with our first 40 cases. MATERIALS AND METHODS We retrospectively reviewed patients who underwent PNB before computed tomography (CT)- or ultrasound-guided lung nodule biopsy from April 2015 through March 2020. Patient demographics, CT fluoroscopy time, radiation dose, complications, diagnostic yield, and effectiveness of PNB were recorded. Effectiveness of PNB was based on direct observation of diaphragmatic motion. Control group data for biopsies during the same time frame were collected and matched with nodules ≤1 cm from the PNB group. RESULTS Among 40 patients identified, no complications occurred related to the PNB. Mean (SD) nodule size was 12.4 (6.2) mm. True-positive results were obtained in 39 patients (98%), with 1 false-negative after an ineffective PNB. PNB was effective in 70%. When CT fluoroscopy was used for the biopsy, radiation dose was significantly lower after an effective PNB than an ineffective PNB (p < .001). Effective PNB was significantly more common with injection of ≥4 mL of local anesthetic (p = .01). Comparison with 19 matched controls showed significantly fewer instances of pneumothorax (p = .02) and greater diagnostic success (p = .03) for the PNB group. CONCLUSION Ultrasound-guided PNB is safe and effective and can improve outcomes when used before lung nodule biopsy.
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Patel Z, Franz CK, Bharat A, Walter JM, Wolfe LF, Koralnik IJ, Deshmukh S. Diaphragm and Phrenic Nerve Ultrasound in COVID-19 Patients and Beyond: Imaging Technique, Findings, and Clinical Applications. JOURNAL OF ULTRASOUND IN MEDICINE : OFFICIAL JOURNAL OF THE AMERICAN INSTITUTE OF ULTRASOUND IN MEDICINE 2022; 41:285-299. [PMID: 33772850 PMCID: PMC8250472 DOI: 10.1002/jum.15706] [Citation(s) in RCA: 12] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 12/14/2020] [Revised: 03/03/2021] [Accepted: 03/13/2021] [Indexed: 05/23/2023]
Abstract
The diaphragm, the principle muscle of inspiration, is an under-recognized contributor to respiratory disease. Dysfunction of the diaphragm can occur secondary to lung disease, prolonged ventilation, phrenic nerve injury, neuromuscular disease, and central nervous system pathology. In light of the global pandemic of coronavirus disease 2019 (COVID-19), there has been growing interest in the utility of ultrasound for evaluation of respiratory symptoms including lung and diaphragm sonography. Diaphragm ultrasound can be utilized to diagnose diaphragm dysfunction, assess severity of dysfunction, and monitor disease progression. This article reviews diaphragm and phrenic nerve ultrasound and describes clinical applications in the context of COVID-19.
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Affiliation(s)
- Zaid Patel
- AMITA Health Saint Francis HospitalEvanstonIllinoisUSA
| | - Colin K. Franz
- Shirley Ryan Ability Lab (Formerly the Rehabilitation Institute of Chicago)ChicagoIllinoisUSA
- Department of Physical Medicine and RehabilitationNorthwestern University Feinberg School of MedicineChicagoIllinoisUSA
- Department of NeurologyNorthwestern University Feinberg School of MedicineChicagoIllinoisUSA
| | - Ankit Bharat
- Division of Thoracic Surgery, Department of SurgeryNorthwestern University Feinberg School of MedicineChicagoIllinoisUSA
- Division of Pulmonary and Critical Care, Department of MedicineNorthwestern University Feinberg School of MedicineChicagoIllinoisUSA
| | - James M. Walter
- Division of Pulmonary and Critical Care, Department of MedicineNorthwestern University Feinberg School of MedicineChicagoIllinoisUSA
| | - Lisa F Wolfe
- Department of NeurologyNorthwestern University Feinberg School of MedicineChicagoIllinoisUSA
- Division of Pulmonary and Critical Care, Department of MedicineNorthwestern University Feinberg School of MedicineChicagoIllinoisUSA
| | - Igor J. Koralnik
- Department of NeurologyNorthwestern University Feinberg School of MedicineChicagoIllinoisUSA
| | - Swati Deshmukh
- Department of RadiologyNorthwestern University Feinberg School of MedicineChicagoIllinoisUSA
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The terminal segment of the human phrenic nerve as a novel implantation site for diaphragm pacing electrodes: Anatomical and clinical description. Ann Anat 2021; 239:151835. [PMID: 34562604 DOI: 10.1016/j.aanat.2021.151835] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/24/2021] [Revised: 08/04/2021] [Accepted: 09/16/2021] [Indexed: 11/22/2022]
Abstract
BACKGROUND Diaphragm pacing allows certain ventilator-dependent patients to achieve weaning from mechanical ventilation. The reference method consists in implanting intrathoracic contact electrodes around the phrenic nerve during video-assisted thoracic surgery, which involves time-consuming phrenic nerve dissection with a risk of nerve damage. Identifying a phrenic segment suitable for dissection-free implantation of electrodes would constitute progress. STUDY DESIGN This study characterizes a free terminal phrenic segment never fully described before. We conducted a cadaver study (n = 14) and a clinical observational study during thoracic procedures (n = 54). RESULTS A free terminal phrenic segment was observed on both sides in 100% of cases, "jumping" from the pericardium to the diaphragm and measuring 60 mm [95% confidence interval; 48-63] and 72.5 mm [65-82] (right left, respectively; p = 0.0038; cadaver study). This segment rolled up on itself at end-expiration and became unravelled and elongated with diaphragm descent (clinical study). Three categories of fat pads were defined (type 1: pericardiophrenic bundle free of surrounding fat; type 2: single fatty fringe leaving the phrenic nerve visible until diaphragmatic entry; type 3: multiple fatty fringes masking the site of penetration of the phrenic nerve) that depended on body mass index (p = 0.001, clinical study). Hematoxylin-eosin and toluidine blue staining (cadaver study) showed that all of the phrenic fibers in the distal, pre-branching part of the terminal segment were contained within a single epineurium containing a variable number of fascicles (right: 1 [95%CI 0.65-4.01]; left 5 [3.37-7.63]; p = 0.03). CONCLUSION Diaphragm pacing through periphrenic electrodes positioned on the terminal phrenic segment should be tested.
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Suratos CT, Takamatsu N, Yamazaki H, Osaki Y, Fukumoto T, Nodera H, Izumi Y. Utility of phrenic nerve ultrasound in amyotrophic lateral sclerosis. Acta Neurol Belg 2021; 121:225-230. [PMID: 33136272 PMCID: PMC7937596 DOI: 10.1007/s13760-020-01531-y] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/03/2020] [Accepted: 10/05/2020] [Indexed: 11/02/2022]
Abstract
Amyotrophic lateral sclerosis (ALS) is a neurodegenerative disorder affecting the upper and lower motor neurons causing progressive weakness. It eventually involves the diaphragm which leads to respiratory paralysis and subsequently death. Phrenic nerve (PN) conduction studies and diaphragm ultrasound has been studied and correlated with pulmonary function tests in ALS patients. However, PN ultrasonography has not been employed in ALS. This study aims to sonographically evaluate the morphologic appearance of the PN of ALS patients. Thirty-eight ALS patients and 28 normal controls referred to the neurophysiology laboratory of two institutions were retrospectively included in the study. Baseline demographic and clinical variables such as disease duration, ALS Functional Rating Scale-Revised score, and ALS region of onset were collected. Ultrasound was used to evaluate the PN cross-sectional area (CSA) of ALS and control subjects. The mean PN CSA of ALS patients were 1.08 ± 0.39 mm on the right and 1.02 ± 0.34 mm on the left. The PN CSA of ALS patients were significantly decreased compared to controls (p value < 0.00001). The PN CSA of ALS patients was not correlated to any of the demographic and clinical parameters tested. This study demonstrates that ALS patients have a smaller PN size compared to controls using ultrasonography.
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Kim HY, Soh EY, Lee J, Kwon SH, Hur M, Min SK, Kim JS. Incidence of hemi-diaphragmatic paresis after ultrasound-guided intermediate cervical plexus block: a prospective observational study. J Anesth 2020; 34:483-490. [PMID: 32236682 DOI: 10.1007/s00540-020-02770-2] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/22/2020] [Accepted: 03/21/2020] [Indexed: 11/26/2022]
Abstract
PURPOSE An intermediate cervical plexus block (CPB) targets the posterior cervical space between the sternocleidomastoid muscle and the prevertebral fascia. The phrenic nerve descends obliquely on the surface of the anterior scalene muscle beneath the prevertebral fascia after originating from the C3-C5 ventral rami. Therefore, the phrenic nerve can be affected by a local anesthetic during an intermediate CPB, depending on the permeability characteristics of the prevertebral fascia. This study investigated whether an intermediate CPB affects the phrenic nerve, inducing hemidiaphragmatic paresis. METHODS In this prospective observational study, 20 patients undergoing single-incision transaxillary robot-assisted right thyroidectomy were enrolled. The intermediate CPB (0.25% ropivacaine 0.2 ml/kg) was performed at the C4-5 intervertebral level carefully, without penetrating the prevertebral fascia, before the patient emerged from general anesthesia. Diaphragmatic motions of the block side were measured by M-mode ultrasonography at three time points: before anesthesia (baseline) and at 30 and 60 min after the intermediate CPB. Hemidiaphragmatic paresis was divided into three grades, depending on the percentage of diaphragm movement compared to the baseline: none (> 75%), partial paresis (25-75%), and complete paresis (< 25%). RESULTS No patient showed any partial or complete ipsilateral hemidiaphragmatic paresis within 60 min after the intermediate CPB. CONCLUSION Intermediate CPB using 0.2 ml/kg of 0.25% ropivacaine at the C4-5 intervertebral level did not cause ipsilateral hemidiaphragmatic paresis. This may imply that the effect of the intermediate CPB on the phrenic nerve is not significant.
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Affiliation(s)
- Ha Yeon Kim
- Department of Anesthesiology and Pain Medicine, Ajou University School of Medicine, 164 Worldcup-ro Yeongtong-gu, Suwon, 16499, Republic of Korea
| | - Euy Young Soh
- Department of Surgery, Ajou University School of Medicine, 164 Worldcup-ro Yeongtong-gu, Suwon, 16499, Republic of Korea
| | - Jeonghun Lee
- Department of Surgery, Ajou University School of Medicine, 164 Worldcup-ro Yeongtong-gu, Suwon, 16499, Republic of Korea
| | - Sei Hyuk Kwon
- Department of Anesthesiology and Pain Medicine, Ajou University School of Medicine, 164 Worldcup-ro Yeongtong-gu, Suwon, 16499, Republic of Korea
| | - Min Hur
- Department of Anesthesiology and Pain Medicine, Ajou University School of Medicine, 164 Worldcup-ro Yeongtong-gu, Suwon, 16499, Republic of Korea
| | - Sang-Kee Min
- Department of Anesthesiology and Pain Medicine, Ajou University School of Medicine, 164 Worldcup-ro Yeongtong-gu, Suwon, 16499, Republic of Korea
| | - Jin-Soo Kim
- Department of Anesthesiology and Pain Medicine, Ajou University School of Medicine, 164 Worldcup-ro Yeongtong-gu, Suwon, 16499, Republic of Korea.
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Heo Y, Cho N, Cho H, Won HS, Yang M, Kim YD. New insights into pathways of the accessory nerve and transverse cervical artery for distal selective accessory nerve blockade. Korean J Pain 2020; 33:48-53. [PMID: 31888317 PMCID: PMC6944375 DOI: 10.3344/kjp.2020.33.1.48] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/31/2019] [Revised: 09/06/2019] [Accepted: 09/10/2019] [Indexed: 12/02/2022] Open
Abstract
Background The aim of this study was to clarify the topographical relationship between the accessory nerve (AN) and transverse cervical artery (TCA) to provide safe and convenient injection points for AN blockade. Methods This study included 21 and 30 shoulders of 14 embalmed Korean adult cadavers and 15 patients, respectively, for dissection and ultrasound (US) examination. Results The courses of the TCA and AN in the scapular region were classified into four types based on their positional relationships. Type A indicated the nerve that was medial to the artery and ran parallel without changing its location (38%). In type B (38%), the nerve was lateral to the artery and ran parallel without changing its location. In type C (19%), the nerve or artery traversed each other only once during the whole course. In type D (5%), the nerve or artery traversed each other more than twice forming a twist. At the levels of lines I–IV, the nerve was relatively close to the artery (approximately 10 mm). TCAs were observed in all specimens around the superior angle of the scapula at the level of line II, whereas they were not found below line VI. In US images of the patients, the TCA was commonly observed at the level of line II (93.3%) where all ANs and TCAs were observed in cadaveric dissection. Conclusions The results expand the current knowledge of the relation between the AN and TCA, and provide helpful information for selective diagnostic nerve blocks in the scapular region.
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Affiliation(s)
- Yanguk Heo
- Department of Anatomy, Wonkwang University School of Medicine, Iksan, Korea.,Jesaeng-Euise Clinical Anatomy Center, Wonkwang University School of Medicine, Iksan, Korea
| | - Namju Cho
- Department of Anatomy, Wonkwang University School of Medicine, Iksan, Korea
| | - Hyunho Cho
- Jesaeng-Euise Clinical Anatomy Center, Wonkwang University School of Medicine, Iksan, Korea.,Department of Anesthesiology and Pain Medicine, Wonkwang University Hospital, Wonkwang University School of Medicine, Iksan, Korea
| | - Hyung-Sun Won
- Department of Anatomy, Wonkwang University School of Medicine, Iksan, Korea.,Jesaeng-Euise Clinical Anatomy Center, Wonkwang University School of Medicine, Iksan, Korea
| | - Miyoung Yang
- Department of Anatomy, Wonkwang University School of Medicine, Iksan, Korea.,Jesaeng-Euise Clinical Anatomy Center, Wonkwang University School of Medicine, Iksan, Korea
| | - Yeon-Dong Kim
- Jesaeng-Euise Clinical Anatomy Center, Wonkwang University School of Medicine, Iksan, Korea.,Department of Anesthesiology and Pain Medicine, Wonkwang University Hospital, Wonkwang University School of Medicine, Iksan, Korea.,Wonkwang Institute of Science, Wonkwang University School of Medicine, Iksan, Korea
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Walter U, Tsiberidou P. Differential age-, gender-, and side-dependency of vagus, spinal accessory, and phrenic nerve calibers detected with precise ultrasonography measures. Muscle Nerve 2019; 59:486-491. [DOI: 10.1002/mus.26412] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/21/2018] [Revised: 12/27/2018] [Accepted: 01/05/2019] [Indexed: 12/13/2022]
Affiliation(s)
- Uwe Walter
- Department of Neurology; University of Rostock; Rostock Germany
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The human phrenic nerve serves as a morphological conduit for autonomic nerves and innervates the caval body of the diaphragm. Sci Rep 2018; 8:11697. [PMID: 30076368 PMCID: PMC6076324 DOI: 10.1038/s41598-018-30145-x] [Citation(s) in RCA: 16] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/09/2018] [Accepted: 07/16/2018] [Indexed: 01/08/2023] Open
Abstract
Communicating fibres between the phrenic nerve and sympathetic nervous system may exist, but have not been characterized histologically and immunohistochemically, even though increased sympathetic activity due to phrenic nerve stimulation for central sleep apnoea may entail morbidity and mortality. We, therefore, conducted a histological study of the phrenic nerve to establish the presence of catecholaminergic fibres throughout their course. The entire phrenic nerves of 35 formalin-fixed human cadavers were analysed morphometrically and immunohistochemically. Furthermore, the right abdominal phrenic nerve was serially sectioned and reconstructed. The phrenic nerve contained 3 ± 2 fascicles in the neck that merged to form a single fascicle in the thorax and split again into 3 ± 3 fascicles above the diaphragm. All phrenic nerves contained catecholaminergic fibres, which were distributed homogenously or present as distinct areas within a fascicle or as separate fascicles. The phrenicoabdominal branch of the right phrenic nerve is a branch of the celiac plexus and, therefore, better termed the “phrenic branch of the celiac plexus”. The wall of the inferior caval vein in the diaphragm contained longitudinal strands of myocardium and atrial natriuretic peptide-positive paraganglia (“caval bodies”) that where innervated by the right phrenic nerve.
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Joeng ES, Jeong YC, Park BJ, Kang S, Yang SN, Yoon JS. Sonoanatomical Change of Phrenic Nerve According to Posture During Ultrasound-Guided Stellate Ganglion Block. Ann Rehabil Med 2016; 40:244-51. [PMID: 27152274 PMCID: PMC4855118 DOI: 10.5535/arm.2016.40.2.244] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/06/2015] [Accepted: 08/12/2015] [Indexed: 02/03/2023] Open
Abstract
Objective To evaluate the risk of phrenic nerve injury during ultrasound-guided stellate ganglion block (US-SGB) according to sonoanatomy of the phrenic nerve, and determine a safer posture for needle insertion by assessing its relationship with surrounding structure according to positional change. Methods Twenty-nine healthy volunteers were recruited and underwent ultrasound in two postures, i.e., supine position with the neck extension and head rotation, and lateral decubitus position. The transducer was placed at the anterior tubercle of the C6 level to identify phrenic nerve. The cross-sectional area (CSA), depth from skin, distance between phrenic nerve and anterior tubercle of C6 transverse process, and the angle formed by anterior tubercle, posterior tubercle and phrenic nerve were measured. Results The phrenic nerve was clearly identified in the intermuscular fascia layer between the anterior scalene and sternocleidomastoid muscles. The distance between the phrenic nerve and anterior tubercle was 10.33±3.20 mm with the supine position and 9.20±3.31 mm with the lateral decubitus position, respectively. The mean CSA and skin depth of phrenic nerve were not statistically different between the two positions. The angle with the supine position was 48.37°±27.43°, and 58.89°±30.02° with the lateral decubitus position. The difference of angle between the two positions was statistically significant. Conclusion Ultrasound is a useful tool for assessing the phrenic nerve and its anatomical relation with other cervical structures. In addition, lateral decubitus position seems to be safer by providing wider angle for needle insertion than the supine position in US-SGB.
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Affiliation(s)
- Eui Soo Joeng
- Department of Physical Medicine and Rehabilitation, Korea University Guro Hospital, Seoul, Korea
| | - Young Cheol Jeong
- Department of Physical Medicine and Rehabilitation, Korea University Guro Hospital, Seoul, Korea
| | - Bum Jun Park
- Department of Physical Medicine and Rehabilitation, Korea University Guro Hospital, Seoul, Korea
| | - Seok Kang
- Department of Physical Medicine and Rehabilitation, Korea University Guro Hospital, Seoul, Korea
| | - Seung Nam Yang
- Department of Physical Medicine and Rehabilitation, Korea University Guro Hospital, Seoul, Korea
| | - Joon Shik Yoon
- Department of Physical Medicine and Rehabilitation, Korea University Guro Hospital, Seoul, Korea
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Ultrasound standard of peripheral nerve block for shoulder arthroscopy: a single-penetration double-injection approach targeting the superior trunk and supraclavicular nerve in the lateral decubitus position. Br J Anaesth 2016; 116:574-5. [DOI: 10.1093/bja/aev459] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/14/2022] Open
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Lin JA, Chuang TY, Yao HY, Yang SF, Tai YT. Ultrasound standard of peripheral nerve block for shoulder arthroscopy: a single-penetration double-injection approach targeting the superior trunk and supraclavicular nerve in the lateral decubitus position. Br J Anaesth 2016; 115:932-4. [PMID: 26582855 DOI: 10.1093/bja/aev384] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/06/2023] Open
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Ha EJ, Baek JH, Lee JH. Ultrasonography-Based Thyroidal and Perithyroidal Anatomy and Its Clinical Significance. Korean J Radiol 2015; 16:749-66. [PMID: 26175574 PMCID: PMC4499539 DOI: 10.3348/kjr.2015.16.4.749] [Citation(s) in RCA: 77] [Impact Index Per Article: 8.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/04/2014] [Accepted: 05/13/2015] [Indexed: 12/21/2022] Open
Abstract
Ultrasonography (US)-guided procedures such as ethanol ablation, radiofrequency ablation, laser ablation, selective nerve block, and core needle biopsy have been widely applied in the diagnosis and management of thyroid and neck lesions. For a safe and effective US-guided procedure, knowledge of neck anatomy, particularly that of the nerves, vessels, and other critical structures, is essential. However, most previous reports evaluated neck anatomy based on cadavers, computed tomography, or magnetic resonance imaging rather than US. Therefore, the aim of this article was to elucidate US-based thyroidal and perithyroidal anatomy, as well as its clinical significance in the use of prevention techniques for complications during the US-guided procedures. Knowledge of these areas may be helpful for maximizing the efficacy and minimizing the complications of US-guided procedures for the thyroid and other neck lesions.
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Affiliation(s)
- Eun Ju Ha
- Department of Radiology, Ajou University School of Medicine, Suwon 443-380, Korea
| | - Jung Hwan Baek
- Department of Radiology and Research Institute of Radiology, University of Ulsan College of Medicine, Asan Medical Center, Seoul 138-736, Korea
| | - Jeong Hyun Lee
- Department of Radiology and Research Institute of Radiology, University of Ulsan College of Medicine, Asan Medical Center, Seoul 138-736, Korea
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Liu Y, Xu XC, Zou Y, Li SR, Zhang B, Wang Y. Phrenic nerve transfer to the musculocutaneous nerve for the repair of brachial plexus injury: electrophysiological characteristics. Neural Regen Res 2015; 10:328-33. [PMID: 25883637 PMCID: PMC4392686 DOI: 10.4103/1673-5374.152388] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 12/14/2014] [Indexed: 11/04/2022] Open
Abstract
Phrenic nerve transfer is a major dynamic treatment used to repair brachial plexus root avulsion. We analyzed 72 relevant articles on phrenic nerve transfer to repair injured brachial plexus that were indexed by Science Citation Index. The keywords searched were brachial plexus injury, phrenic nerve, repair, surgery, protection, nerve transfer, and nerve graft. In addition, we performed neurophysiological analysis of the preoperative condition and prognosis of 10 patients undergoing ipsilateral phrenic nerve transfer to the musculocutaneous nerve in our hospital from 2008 to 201 3 and observed the electromyograms of the biceps brachii and motor conduction function of the musculocutaneous nerve. Clinically, approximately 28% of patients had brachial plexus injury combined with phrenic nerve injury, and injured phrenic nerve cannot be used as a nerve graft. After phrenic nerve transfer to the musculocutaneous nerve, the regenerated potentials first appeared at 3 months. Recovery of motor unit action potential occurred 6 months later and became more apparent at 12 months. The percent of patients recovering 'excellent' and 'good' muscle strength in the biceps brachii was 80% after 18 months. At 12 months after surgery, motor nerve conduction potential appeared in the musculocutaneous nerve in seven cases. These data suggest that preoperative evaluation of phrenic nerve function may help identify the most appropriate nerve graft in patients with an injured brachial plexus. The functional recovery of a transplanted nerve can be dynamically observed after the surgery.
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Affiliation(s)
- Ying Liu
- Department of Neurology, Sichuan Academy of Medical Sciences and Sichuan Provincial People's Hospital, Chengdu, Sichuan Province, China
| | - Xun-Cheng Xu
- Department of Neurology, Sichuan Academy of Medical Sciences and Sichuan Provincial People's Hospital, Chengdu, Sichuan Province, China
| | - Yi Zou
- Department of Neurology, Sichuan Academy of Medical Sciences and Sichuan Provincial People's Hospital, Chengdu, Sichuan Province, China
| | - Su-Rong Li
- Department of Neurology, Sichuan Academy of Medical Sciences and Sichuan Provincial People's Hospital, Chengdu, Sichuan Province, China
| | - Bin Zhang
- Department of Orthopedics, Sichuan Academy of Medical Sciences and Sichuan Provincial People's Hospital, Chengdu, Sichuan Province, China
| | - Yue Wang
- Department of Orthopedics, Sichuan Academy of Medical Sciences and Sichuan Provincial People's Hospital, Chengdu, Sichuan Province, China
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Junior WM, de Carvalho Alcântara M, Nogueira-Barbosa MH, Fernandes RMF, da Silva GA, Sander HH, Lourenço CM. Respiratory dysfunction in Charcot–Marie–Tooth disease type 1A. J Neurol 2015; 262:1164-71. [DOI: 10.1007/s00415-015-7677-8] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/30/2014] [Revised: 02/06/2015] [Accepted: 02/07/2015] [Indexed: 11/29/2022]
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Anatomical study of spinal accessory nerve using ultrasonography. Eur J Radiol 2013; 82:56-61. [DOI: 10.1016/j.ejrad.2011.04.038] [Citation(s) in RCA: 19] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/15/2011] [Accepted: 03/29/2011] [Indexed: 12/16/2022]
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Moraux A, Vandenbussche L, Demondion X, Gheno R, Pansini V, Cotten A. Anatomical study of the pisotriquetral joint ligaments using ultrasonography. Skeletal Radiol 2012; 41:321-8. [PMID: 21560006 DOI: 10.1007/s00256-011-1188-1] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/19/2011] [Revised: 04/22/2011] [Accepted: 04/25/2011] [Indexed: 02/02/2023]
Abstract
OBJECTIVE The aim of this study was to demonstrate that ultrasonography may allow a precise assessment of the primary stabilizers of pisotriquetral joint (pisohamate, pisometacarpal, and ulnar pisotriquetral ligaments). METHODS AND MATERIALS This study was initially undertaken in eight cadavers. Metal markers were placed in the ligaments using ultrasonographic guidance, followed by the dissection of the wrists. High-resolution ultrasonography was then performed in 15 volunteers (30 wrists) for the analysis of the presence, appearance, and thickness of the ligaments. RESULTS At dissection, the metal markers were located in the ligaments or immediately adjacent to them, confirming that they were correctly depicted using ultrasonography. The three ligaments could also be identified in each volunteer. The optimal positioning of the probe and the dynamic maneuvers of the wrist allowing the strain of these ligaments could be defined. No significant changes in the appearance and thickness of the ligaments could be observed. CONCLUSIONS The three ligaments stabilizing the pisotriquetral joint can be identified using ultrasonography. Further studies are now required to know whether this knowledge may be useful in the assessment of pain involving the ulnar part of the wrist.
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Affiliation(s)
- Antoine Moraux
- Service d'Imagerie Musculo-Squelettique, Centre de consultation de l'appareil locomoteur, Hôpital Roger Salengro, 2 Bd du Pr E. Laine, CHRU Lille, 59037, Lille Cedex, France
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An anatomical study of the full-length phrenic nerve and its blood supply: clinical implications for endoscopic dissection. Anat Sci Int 2011; 86:225-31. [DOI: 10.1007/s12565-011-0114-x] [Citation(s) in RCA: 17] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/01/2011] [Accepted: 08/17/2011] [Indexed: 11/24/2022]
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Kuusniemi K, Pyylampi V. Phrenic nerve block with ultrasound-guidance for treatment of hiccups: a case report. J Med Case Rep 2011; 5:493. [PMID: 21968133 PMCID: PMC3193825 DOI: 10.1186/1752-1947-5-493] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/10/2011] [Accepted: 10/03/2011] [Indexed: 11/10/2022] Open
Abstract
INTRODUCTION Persistent hiccups can be more than a simple and short-lived nuisance and therefore sometimes call for serious consideration. Hiccupping episodes that last only a few minutes may be annoying, but persistent hiccups may initiate many major complications. CASE PRESENTATION A 72-year-old Caucasian man with spinal stenosis presented for L4-5 laminectomy under spinal anesthesia. The surgery and anesthesia, as well as the perioperative period, passed without any incident, except for persistent postoperative hiccups not responding to conservative and pharmacological treatment. Hiccups resulted in a prolonged hospital stay as they lasted until the seventh postoperative day. On that day, a right-sided ultrasound-guided phrenic nerve block with 5 ml of bupivacaine 5 mg/ml with epinephrine was performed successfully with a single-injection technique. Ten minutes after the procedure the hiccups vanished and a partial sensomotoric block of his right shoulder developed. No adverse effect occurred; our patient could be discharged on the same day and the hiccups did not return. CONCLUSION Ultrasound provides us with non-invasive information regarding anatomy and allows anesthesiologists to visualize needle insertion, to identify the exact location of the injected solution and to avoid such structures as arteries or veins. As such, this method should be actively utilized. In cases where both pharmacological and non-pharmacological treatments prove to be ineffective when treating persistent hiccups, a single-shot ultrasound-guided technique should be considered before the patient becomes exhausted.
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Affiliation(s)
- Kristiina Kuusniemi
- Department of Anaesthesiology, Intensive Care, Emergency Care and Pain Medicine, Turku University Hospital, Luolavuorentie 2, Turku 20700, FI-20520, Finland.
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Ipsilateral Brachial Plexus Block and Hemidiaphragmatic Paresis as Adverse Effect of a High Thoracic Paravertebral Block. Reg Anesth Pain Med 2011; 36:198-201. [DOI: 10.1097/aap.0b013e31820d424c] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/28/2023]
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Minimum Effective Volume of Local Anesthetic for Shoulder Analgesia by Ultrasound-Guided Block at Root C7 With Assessment of Pulmonary Function. Reg Anesth Pain Med 2010; 35:529-34. [DOI: 10.1097/aap.0b013e3181fa1190] [Citation(s) in RCA: 78] [Impact Index Per Article: 5.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
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Zhu J, Liu F, Li D, Shao J, Hu B. Preliminary study of the types of traumatic peripheral nerve injuries by ultrasound. Eur Radiol 2010; 21:1097-101. [PMID: 20972875 DOI: 10.1007/s00330-010-1992-3] [Citation(s) in RCA: 36] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/09/2010] [Revised: 08/24/2010] [Accepted: 09/25/2010] [Indexed: 01/25/2023]
Abstract
OBJECTIVES To investigate the types of traumatic peripheral nerve injuries by ultrasound (US). To demonstrate the efficacy of US in case of peripheral nerve injuries and, in particular, its importance of demonstrating and monitoring the appearances of the nerve itself. METHODS Two hundred and two patients, of which 117 subsequently underwent operative treatment, were prospectively examined by US in such a way that the transducer was moved to the nerve damaged region from the normal nerve located near a known anatomical landmark. The ultrasound features of the traumatic peripheral nerve injuries were classified according to abnormal fascicle, perineurium, epineurium, and peripheral tissues of peripheral nerve. RESULTS The ultrasound features of the traumatic peripheral nerve injuries were classified into 7 types. In the 117 cases that underwent operative treatment, the accuracy of classification by using US was 93.2%. CONCLUSIONS Ultrasound seems to be a valuable investigation for evaluating the type of traumatic peripheral nerve injury.
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Affiliation(s)
- Jiaan Zhu
- Department of Ultrasound in Medicine, Shanghai Jiao Tong University Affiliated Sixth People's Hospital, 600 Yishan Rd, Shanghai 200233, China.
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Kang KN, Park IK, Suh JH, Leem JG, Shin JW. Ultrasound-guided Pulsed Radiofrequency Lesioning of the Phrenic Nerve in a Patient with Intractable Hiccup. Korean J Pain 2010; 23:198-201. [PMID: 20830266 PMCID: PMC2935982 DOI: 10.3344/kjp.2010.23.3.198] [Citation(s) in RCA: 23] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/23/2010] [Revised: 07/29/2010] [Accepted: 07/30/2010] [Indexed: 11/24/2022] Open
Abstract
Persistent and intractable hiccups (with respective durations of more than 48 hours and 1 month) can result in depression, fatigue, impaired sleep, dehydration, weight loss, malnutrition, and aspiration syndromes. The conventional treatments for hiccups are either non-pharmacological, pharmacological or a nerve block treatment. Pulsed radiofrequency lesioning (PRFL) has been proposed for the modulation of the excited nervous system pathway of pain as a safe and nondestructive treatment method. As placement of the electrode in close proximity to the targeted nerve is very important for the success of PRFL, ultrasound appears to be well suited for this technique. A 74-year-old man suffering from intractable hiccups that had developed after a coronary artery bypass graft and had continued for 7 years was referred to our pain clinic. He had not been treated with conventional methods or medications. We performed PRFL of the phrenic nerve guided by ultrasound and the hiccups disappeared.
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Affiliation(s)
- Keum Nae Kang
- Department of Anesthesiology and Pain Medicine, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Korea
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