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Khadanovich A, Benes M, Kaiser R, Herma T, Kachlik D. Clinical anatomy of the lateral antebrachial cutaneous nerve: Is there any safe zone for interventional approach? Ann Anat 2024; 252:152202. [PMID: 38128746 DOI: 10.1016/j.aanat.2023.152202] [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: 11/03/2023] [Revised: 12/13/2023] [Accepted: 12/15/2023] [Indexed: 12/23/2023]
Abstract
INTRODUCTION The lateral antebrachial cutaneous nerve (LACN) is a somatosensory nerve coursing in the lateral portion of the forearm. The nerve is located in a close proximity to the cephalic vein (CV) all along its course with a danger of being injured during venipuncture. The LACN also overlaps and communicates with the superficial branch of the radial nerve (SBRN) in the distal forearm and hand, making the awareness of their relationship of great importance in the treatment of neuroma. The aim of the study was to observe the relationship of the LACN to surrounding structures as well as its branching pattern and distribution. MATERIALS AND METHODS Ninety-three cadaveric forearms embalmed in formaldehyde were dissected. The relationship of the LACN to surrounding structures was noted and photographed, and distances between the structures were measured with a digital caliper. The cross-sectional relationships of the LACN and SBRN to the CV were described using heatmaps. RESULTS The emerging point of the LACN was found distally, proximally or at the level of the interepicondylar line (IEL). The LACN branched in 76 cases (81.7 %) into an anterior and posterior branch at mean distance of 47.8 ± 34.2 mm distal to the IEL. The sensory distribution was described according to the relationship of the LACN branches to the medial border of the brachioradialis muscle. The LACN supplying the dorsum of the hand was observed in 39.8 % of cases. The LACN and the SBRN intersected in 86 % of upper limbs with communications noticed in 71 % of forearms. The LACN was stated as the most frequent donor of the communicating branch resulting in neuroma located distal to the communication and being fed from the LACN. The relationship of the LACN and the CV showed that the IEL is the most appropriate place for the venipuncture due to maximal calibers of the CV and deep position of the LACN. The LACN was adjacent to the cubital perforating vein and the radial artery in all cases. The medial border of the brachioradialis muscle was observed less than 1.8 mm from the LACN. CONCLUSION The study provides morphological data on the LACN distribution, branching pattern and relationship to surrounding structures in a context of clinical use in different spheres of medicine. The branching pattern of the LACN appears to be more constant compared to data provided by previous authors. We emphasized the meaning of cross-sectional relationship of the LACN to the CV to avoid venipuncture outside the cubital fossa if possible. The posterior branch of the LACN was predicted as appropriate donor of the graft for a digital nerve. The LACN appeared to be in a close proximity within the whole length of the brachioradialis muscle what the orthopedic surgeons must be concerned of. The meaning of the donor-nerve of the communicating branch in neuroma treatment was also introduced.
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Affiliation(s)
- Anhelina Khadanovich
- Department of Anatomy, Second Faculty of Medicine, Charles University, Prague, Czech Republic; Center for Endoscopic, Surgical and Clinical Anatomy (CESKA), Second Faculty of Medicine, Charles University, Prague, Czech Republic
| | - Michal Benes
- Department of Anatomy, Second Faculty of Medicine, Charles University, Prague, Czech Republic; Center for Endoscopic, Surgical and Clinical Anatomy (CESKA), Second Faculty of Medicine, Charles University, Prague, Czech Republic
| | - Radek Kaiser
- Center for Endoscopic, Surgical and Clinical Anatomy (CESKA), Second Faculty of Medicine, Charles University, Prague, Czech Republic; First Faculty of Medicine, Charles University, Prague, Czech Republic; Spinal Surgery Unit, Oxford University Hospitals NHS Foundation Trust, Oxford, UK
| | - Tomas Herma
- Department of Anatomy, Second Faculty of Medicine, Charles University, Prague, Czech Republic; Center for Endoscopic, Surgical and Clinical Anatomy (CESKA), Second Faculty of Medicine, Charles University, Prague, Czech Republic
| | - David Kachlik
- Department of Anatomy, Second Faculty of Medicine, Charles University, Prague, Czech Republic; Center for Endoscopic, Surgical and Clinical Anatomy (CESKA), Second Faculty of Medicine, Charles University, Prague, Czech Republic.
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Zadrazil M, Marhofer P, Columb M, Opfermann P, Schmid W, Marhofer D, Stimpfl T, Reichel S, Al Jalali V, Zeitlinger M. The impact of biological sex in peripheral nerve blockade: A prospective pharmacodynamic, pharmacokinetic and morphometric study in volunteers. PLoS One 2024; 19:e0297095. [PMID: 38277353 PMCID: PMC10817111 DOI: 10.1371/journal.pone.0297095] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/06/2023] [Accepted: 12/19/2023] [Indexed: 01/28/2024] Open
Abstract
STUDY OBJECTIVE The impact of biological sex in peripheral regional anaesthesia is largely unknown. We therefore designed a prospective study in volunteers to investigate the impact of biological sex on pharmacodynamic, pharmacokinetic and morphometric characteristics for peripheral nerve blockade. METHODS The initial study plan was powered to include 90 volunteers to find a difference of 35 min in duration of sensory block (primary outcome variable) with 80% power and alpha error at 5%. After discussions in ethical review, a pilot study of 2 x 12 volunteers from each sex were studied. Female and male volunteers received ultrasound guided nerve blockade with 3.0 mL ropivacaine 7.5 mg mL-1. Sensory duration of blockade, as the primary outcome, was evaluated by pinprick testing. Secondary outcomes were sensory onset time of blockade, pharmacokinetic characteristics and the visibility of ulnar nerves using ultrasound. Analyses included Mann-Whitney U-statistics with P<0.05 (two-sided) as significant. RESULTS After 24 participants, the median (IQR) duration of sensory blockade was 450 (420; 503) min in women and 480 (450; 510) min in men (P = 0.49). Sensory onset time of blockade, and ultrasound visibility of nerves were also similar between the study groups. The total drug exposure across time (AUC0-infinity) was significantly higher in women (P = 0.017). After a the planned power re-analysis after these 24 study paticipants, which suggested that > 400 subjects would be required with 80% power and alpha error of 5% to find significance for the primary outcome parameter for marginal differences, we terminated the study at this point. CONCLUSIONS We did not detect significant differences between female and male study participants in terms of pharmacodynamic and morphometric characteristics after ultrasound guided ulnar nerve blocks. Women did show significantly greater pharmacokinetic ropivacaine exposures. The results of this study indicate that peripheral regional block pharmacodynamic characteristics are independent of the biological sex, whereas pharmacokinetic parameters are sex-dependent.
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Affiliation(s)
- Markus Zadrazil
- Department of Anesthesia and Intensive Care Medicine, Medical University of Vienna, Vienna, Austria
| | - Peter Marhofer
- Department of Anesthesia and Intensive Care Medicine, Medical University of Vienna, Vienna, Austria
| | - Malachy Columb
- Manchester University Hospitals NHS Foundation Trust, Wythenshawe Hospital, Manchester, United Kingdom
| | - Philipp Opfermann
- Department of Anesthesia and Intensive Care Medicine, Medical University of Vienna, Vienna, Austria
| | - Werner Schmid
- Department of Anesthesia and Intensive Care Medicine, Medical University of Vienna, Vienna, Austria
| | - Daniela Marhofer
- Department of Anesthesia and Intensive Care Medicine, Medical University of Vienna, Vienna, Austria
| | - Thomas Stimpfl
- Clinical Department of Laboratory Medicine, Medical University of Vienna, Vienna, Austria
| | - Sabine Reichel
- Clinical Department of Laboratory Medicine, Medical University of Vienna, Vienna, Austria
| | - Valentin Al Jalali
- Department of Clinical Pharmacology, Medical University Vienna, Vienna, Austria
| | - Markus Zeitlinger
- Department of Clinical Pharmacology, Medical University Vienna, Vienna, Austria
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Muñoz-Gómez E, Aguilar-Rodríguez M, Inglés M, Mollà-Casanova S, Sempere-Rubio N, Serra-Añó P. Effects of mirror therapy on pain, sensitivity and functionality in patients with unilateral carpal tunnel syndrome. Randomised control trial. Disabil Rehabil 2023:1-9. [PMID: 37947269 DOI: 10.1080/09638288.2023.2280705] [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: 05/31/2023] [Accepted: 11/02/2023] [Indexed: 11/12/2023]
Abstract
PURPOSE To investigate the effects of mirror therapy (MT) and therapeutic exercise (TE) with the unaffected hand, on pain, sensitivity and functionality in individuals with unilateral carpal tunnel syndrome (CTS). MATERIAL AND METHODS A randomized controlled trial was carried out. Thirty-nine adults with unilateral CTS were included and randomly allocated to a six-week training programme based on MT (n = 20) or TE (n = 19). Visual Analogue Scale, Semmes-Weinstein monofilament test, Two-point discrimination (2PD), Disabilities of the Arm, Shoulder and Hand (DASH) and Boston Carpal Tunnel Questionnaire (BCTQ) were assessed before (T0) and after the intervention (T1), and at one-month follow-up (T2). RESULTS At T1, MT and TE showed significant improvements in pain (p = 0.001 and p = 0.03, respectively), however, only MT maintained the achieved effects at T2 (p = 0.01). In addition, 2PD significantly improved in MT in the first (p = 0.04) and fourth fingers (p = 0.02) at T1. The DASH score decreased at T1 in MT (p < 0.001) and TE (p = 0.01). Additionally, the BCTQ score improved in MT (p < 0.001), and TE (p < 0.001) at T1. The effects were maintained at T2 for DASH and BCTQ scores. CONCLUSIONS Training of the unaffected hand resulted in a significant improvement of the affected hand in both groups; nevertheless, MT achieved a longer duration of the effects.
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Affiliation(s)
- Elena Muñoz-Gómez
- UBIC Group, Department of Physiotherapy, Faculty of Physiotherapy, University of Valencia, Valencia, Spain
| | - Marta Aguilar-Rodríguez
- UBIC Group, Department of Physiotherapy, Faculty of Physiotherapy, University of Valencia, Valencia, Spain
| | - Marta Inglés
- UBIC Group, Department of Physiotherapy, Faculty of Physiotherapy, University of Valencia, Valencia, Spain
| | - Sara Mollà-Casanova
- UBIC Group, Department of Physiotherapy, Faculty of Physiotherapy, University of Valencia, Valencia, Spain
| | - Núria Sempere-Rubio
- UBIC Group, Department of Physiotherapy, Faculty of Physiotherapy, University of Valencia, Valencia, Spain
| | - Pilar Serra-Añó
- UBIC Group, Department of Physiotherapy, Faculty of Physiotherapy, University of Valencia, Valencia, Spain
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Khadanovich A, Herma T, Al-Redouan A, Kaiser R, Kachlik D. The communication patterns between the lateral antebrachial cutaneous nerve and the superficial branch of the radial nerve. Ann Anat 2023:152110. [PMID: 37207848 DOI: 10.1016/j.aanat.2023.152110] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/22/2023] [Revised: 04/20/2023] [Accepted: 05/02/2023] [Indexed: 05/21/2023]
Abstract
INTRODUCTION The superficial branch of the radial nerve (SBRN) and the lateral antebrachial cutaneous nerve (LACN) are sensory nerves coursing within the forearm in a close relationship. This high degree of overlap and eventual communication between the nerves is of great surgical importance. The aim of our study is to identify the communication pattern and overlap of the nerves, to localize the position of this communication in relation to a bony landmark, and to specify the most common communication patterns. MATERIALS and methods: One hundred and two adult formalin-fixed cadaveric forearms from 51 cadavers of Central European origin were meticulously dissected. The SBRN, as well as the LACN, were identified. The morphometric parameters concerning these nerves, as well as their branches and connections, were measured with a digital caliper. RESULTS We have described the primary (PCB) and secondary communications (SCB) between the SBRN and the LACN and their overlap patterns. One hundred and nine PCBs were found in 75 (73.53%) forearms of 44 (86.27%) cadavers and fourteen SCBs in eleven hands (10.78%) of eight cadavers (15.69%). Anatomical and surgical classifications were created. Anatomically, the PCBs were classified in three different ways concerning: (1) the role of the branch of the SBRN within the connection; (2) the position of the communicating branch to the SBRN; and (3) the position of the LACN branch involved in the communication to the cephalic vein (CV). The mean length and width of the PCBs were 17.12mm (ranged from 2.33-82.96mm) and 0.73mm (ranged from 0.14-2.01mm), respectively. The PCB was located proximally to the styloid process of the radius at an average distance of 29.91mm (ranged from 4.15-97.61mm). Surgical classification is based on the localization of the PCBs to a triangular zone of the SBRN branching. The most frequent branch of the SBRN involved in the communication was the third (66.97%). Due to the frequency and position of the PCB with the third branch of the SBRN, the danger zone was predicted. According to the overlap between the SBRN and the LACN, we have divided 102 forearms into four types: (1) no overlap; (2) present overlap; (3) pseudo-overlap; and (4) both present and pseudo-overlap. Type 4 was the most common. CONCLUSION The patterns of communicating branch arrangements appeared to be not just a rare phenomenon or variation, but rather a common situation highlighting clinical importance. Due to the close relationship and connection of these nerves, there is a high probability of simultaneous lesion.
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Affiliation(s)
- Anhelina Khadanovich
- Department of Anatomy, Second Faculty of Medicine, Charles University, Prague, Czech Republic.
| | - Tomas Herma
- Department of Anatomy, Second Faculty of Medicine, Charles University, Prague, Czech Republic; Center for Endoscopic, Surgical and Clinical Anatomy (CESKA), Second Faculty of Medicine, Charles University, Prague, Czech Republic.
| | - Azzat Al-Redouan
- Department of Anatomy, Second Faculty of Medicine, Charles University, Prague, Czech Republic; Center for Endoscopic, Surgical and Clinical Anatomy (CESKA), Second Faculty of Medicine, Charles University, Prague, Czech Republic.
| | - Radek Kaiser
- Center for Endoscopic, Surgical and Clinical Anatomy (CESKA), Second Faculty of Medicine, Charles University, Prague, Czech Republic; Department of Neurosurgery and Neurooncology, First Faculty of Medicine, Charles University and Military University Hospital Prague, Czech Republic.
| | - David Kachlik
- Department of Anatomy, Second Faculty of Medicine, Charles University, Prague, Czech Republic; Center for Endoscopic, Surgical and Clinical Anatomy (CESKA), Second Faculty of Medicine, Charles University, Prague, Czech Republic; Department of Health Care, College of Polytechnics Jihlava, Czech Republic.
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The relationship between the lateral cutaneous antebrachial nerve and the superficial branch of the radial nerve and its impact on regional anesthetic and pain blocks of the thumb; what is more important: nerves or dermatomes? Ann Anat 2022; 245:152018. [DOI: 10.1016/j.aanat.2022.152018] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/04/2022] [Revised: 09/27/2022] [Accepted: 09/29/2022] [Indexed: 11/06/2022]
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Ciano J, Beatty BL. Regional variation in the density of Meissner’s corpuscles in human fingers. Ann Anat 2022; 243:151946. [DOI: 10.1016/j.aanat.2022.151946] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/04/2022] [Revised: 03/07/2022] [Accepted: 03/31/2022] [Indexed: 10/18/2022]
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Opfermann P, Marhofer P, Hopkins PM, Columb MO, Zadrazil M, Stimpfl T, Marhofer M, Zeitlinger M. Generic versus reference listed ropivacaine for peripheral nerve blockade: A randomised, triple-blinded, crossover, equivalence study in volunteers. Eur J Anaesthesiol 2021; 38:S113-S120. [PMID: 33399381 DOI: 10.1097/eja.0000000000001424] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
BACKGROUND Generic drug preparations do not require the same degree of scrutiny as the originally licensed preparation before they can be approved for clinical use. The permitted tolerance limits for bioequivalent preparations might be associated with clinically relevant differences for drugs with a narrow therapeutic index, such as local anaesthetics. OBJECTIVE We compared pharmacokinetic and pharmacodynamic characteristics of generic and reference listed or original preparations of ropivacaine. DESIGN The current healthy volunteer study used a randomised, triple-blinded, cross-over equivalence design. SETTING Tertiary university hospital, Medical University of Vienna. SUBJECTS Healthy male volunteers (N=18) aged 18 to 60 years. INTERVENTIONS A series of three ultrasound-guided ulnar nerve blocks separated by at least 6 days were carried out on each volunteer. Reference listed ropivacaine (NaropinTM) was used for two blocks and a generic preparation of ropivacaine was used for the other block. Sensory block onset and duration were evaluated using loss of pinprick sensation. MAIN OUTCOME MEASURES Duration of sensory block was the primary outcome. Secondary outcomes included time-to-onset of sensory block, ropivacaine pharmacokinetics from venous blood samples and pH of the preparations. Equivalence was evaluated using the ratios of means and 90% confidence intervals (CIs) of log transformed data. RESULTS Equivalence was demonstrated for the primary outcome measure, the duration of sensory block [original : generic ratio 1.01 (90% CI 0.87 to 1.16); P < 0.007] and all pharmacokinetic variables. Equivalence could not be concluded for time-to-onset of sensory block [reference : generic ratio 0.80 (90% CI 0.63 to 1.03); P = 0.27], although reproducibility of this variable using our experimental model was lower than for other variables. The generic preparation was significantly more alkaline [difference 0.06 pH units (95% CI 0.04 to 0.07); P < 0.0001]. CONCLUSION Our finding of equivalence for sensory block duration and key pharmacokinetic variables between a generic and original preparation of ropivacaine is reassuring. The significant, but small, difference in pH is not clinically important. TRIAL REGISTRATION EudraCT 2019-003148-61, German Clinical Trials Register (DRKS 00017750).
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Affiliation(s)
- Philipp Opfermann
- From the Department of Anaesthesiology and General Intensive Care Medicine, Medical University of Vienna, Vienna, Austria (PO, PM, MZ), Orthopaedic Hospital Speising, Department of Anaesthesiology and Intensive Care Medicine, Vienna, Austria (PM), Leeds Institute of Medical Research at St James's, School of Medicine, University of Leeds, Leeds (PMH), Department of Anaesthesia, Manchester University Hospitals Foundation Trust, Wythenshawe, UK (MOC), Clinical Institute of Laboratory Medicine, Toxicology, Medical University of Vienna, Vienna (TS), Medical University of Innsbruck, Innsbruck (MM) and Department of Clinical Pharmacology, Medical University Vienna, Vienna, Austria (MZ)
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Mechanisms of action of the erector spinae plane (ESP) block: a narrative review. Can J Anaesth 2021; 68:387-408. [DOI: 10.1007/s12630-020-01875-2] [Citation(s) in RCA: 76] [Impact Index Per Article: 25.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/20/2020] [Revised: 08/06/2020] [Accepted: 09/06/2020] [Indexed: 12/27/2022] Open
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Feigl GC, Litz RJ, Marhofer P. Anatomy of the brachial plexus and its implications for daily clinical practice: regional anesthesia is applied anatomy. Reg Anesth Pain Med 2020; 45:620-627. [DOI: 10.1136/rapm-2020-101435] [Citation(s) in RCA: 21] [Impact Index Per Article: 5.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/02/2020] [Revised: 05/01/2020] [Accepted: 05/04/2020] [Indexed: 12/29/2022]
Abstract
Safety and effectiveness are mandatory requirements for any technique of regional anesthesia and can only be met by clinicians who appropriately understand all relevant anatomical details. Anatomical texts written for anesthetists may oversimplify the facts, presumably in an effort to reconcile extreme complexity with a need to educate as many users as possible. When it comes to techniques as common as upper-extremity blocks, the need for customized anatomical literature is even greater, particularly because the complex anatomy of the brachial plexus has never been described for anesthetists with a focus placed on regional anesthesia. The authors have undertaken to close this gap by compiling a structured overview that is clinically oriented and tailored to the needs of regional anesthesia. They describe the anatomy of the brachial plexus (ventral rami, trunks, divisions, cords, and nerves) in relation to the topographical regions used for access (interscalene gap, posterior triangle of the neck, infraclavicular fossa, and axillary fossa) and discuss the (interscalene, supraclavicular, infraclavicular, and axillary) block procedures associated with these access regions. They indicate allowances to be made for anatomical variations and the topography of fascial anatomy, give recommendations for ultrasound imaging and needle guidance, and explain the risks of excessive volumes and misdirected spreading of local anesthetics in various anatomical contexts. It is hoped that clinicians will find this article to be a useful reference for decision-making, enabling them to select the most appropriate regional anesthetic technique in any given situation, and to correctly judge the risks involved, whenever they prepare patients for a specific upper-limb surgical procedure.
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Merella F, Mossetti V. Ultrasound-guided upper and lower extremity nerve blocks in children. BJA Educ 2020; 20:42-50. [PMID: 33456929 DOI: 10.1016/j.bjae.2019.11.003] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 11/08/2019] [Indexed: 01/22/2023] Open
Affiliation(s)
- F Merella
- Birmingham Children's Hospital, Birmingham, UK
| | - V Mossetti
- Regina Margherita Children's Hospital, Turin, Italy
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Comment on ‘Cutaneous innervation of the hand: clinical testing in volunteers shows high intra- and inter-individual variability’ (Br J Anaesth 2018; 120: 836–45). Br J Anaesth 2020; 124:e24-e26. [PMID: 31813568 DOI: 10.1016/j.bja.2019.11.004] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/16/2019] [Revised: 11/06/2019] [Accepted: 11/07/2019] [Indexed: 11/18/2022] Open
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Corke PJ. Ultrasound-guided posterior antebrachial cutaneous nerve block utilising the 'fat-filled flat tunnel': Description of technique and cutaneous sensory block area. Anaesth Intensive Care 2019; 47:532-540. [PMID: 31829744 DOI: 10.1177/0310057x19888817] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/14/2023]
Abstract
The aim of the study was to investigate an ultrasound-guided posterior antebrachial cutaneous nerve block based on visualising the nerve within the fat-filled flat tunnel and describe the area of cutaneous sensory loss. A total of 12 healthy volunteers were included in the study. The posterior antebrachial cutaneous nerve was identified within the fat-filled flat tunnel in the upper arm using high-frequency ultrasound. The nerve was blocked using an in-plane needle guidance technique with 1 ml 2% lidocaine. Sensory loss to pinprick was evaluated 15 minutes after performing the block and the cutaneous sensory block area mapped. Ultrasound visualisation of the posterior antebrachial cutaneous nerve in the fat-filled flat tunnel was possible in all volunteers. The median distance of the posterior antebrachial cutaneous nerve to the lateral epicondyle of the elbow was 67.5 (range 54–105) mm. Loss of sharpness sensation to pinprick extended from the posterior aspect of the distal upper arm and posterior forearm to the wrist. The median cutaneous sensory block area was 103 (range 61–341) cm2. Two volunteers had a sensory block over the anterior forearm of 29 and 10 cm2 respectively. This amounted to 11% and 4.5% of the total cutaneous sensory block area. One volunteer had a sensory block over the dorsum of the hand of 39 cm2 (15% of the total cutaneous sensory block area). The results of this study indicate that the fat-filled flat tunnel can be a useful sono-anatomical landmark in identifying the posterior antebrachial cutaneous nerve and may serve as a target for injection. Although sensory block is predominantly confined to the posterior distal arm and forearm, inter-individual variability in the area and distribution was observed. Sensory block in the anterior forearm and dorsum of the hand can occur. The study was prospectively registered at the Australian New Zealand Clinical Trials Registry, identifier ACTRN12618000891224.
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Affiliation(s)
- Philip J Corke
- Department of Anaesthesia and Pain Management, Concord Repatriation General Hospital, Sydney, Australia
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Bowness J, Turnbull K, Taylor A, Halcrow J, Raju P, Mustafa A, Chisholm F, Varsou O, Grant C. Identifying variant anatomy during ultrasound-guided regional anaesthesia: opportunities for clinical improvement. Br J Anaesth 2019; 122:e75-e77. [DOI: 10.1016/j.bja.2019.02.003] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/23/2018] [Revised: 01/30/2019] [Accepted: 02/01/2019] [Indexed: 11/27/2022] Open
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Marhofer P, Columb M, Hopkins PM, Greher M, Marhofer D, Bienzle M, Zeitlinger M. Dexamethasone as an adjuvant for peripheral nerve blockade: a randomised, triple-blinded crossover study in volunteers. Br J Anaesth 2019; 122:525-531. [PMID: 30857609 DOI: 10.1016/j.bja.2019.01.004] [Citation(s) in RCA: 48] [Impact Index Per Article: 9.6] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/09/2018] [Revised: 12/30/2018] [Accepted: 01/02/2019] [Indexed: 11/24/2022] Open
Abstract
BACKGROUND The efficacy of dexamethasone in extending the duration of local anaesthetic block is uncertain. In a randomised controlled triple blind crossover study in volunteers, we tested the hypothesis that neither i.v. nor perineurally administered dexamethasone prolongs the sensory block achieved with ropivacaine. METHODS Ultrasound-guided ulnar nerve blocks (ropivacaine 0.75% wt/vol, 3 ml, with saline 1 ml with or without dexamethasone 4 mg) were performed on three occasions in 24 male volunteers along with an i.v. injection of saline 1 ml with or without dexamethasone 4 mg. The combinations of saline and dexamethasone were as follows: control group, perineural and i.v. saline; perineural group, perineural dexamethasone and i.v. saline; i.v. group, perineural saline and i.v. dexamethasone. Sensory block was measured using a VAS in response to pinprick testing. The duration of sensory block was the primary outcome and time to onset of sensory block the secondary outcome. RESULTS All 24 subjects completed the trial. The median [inter-quartile range (IQR)] duration of sensory block was 6.87 (5.85-7.62) h in the control group, 7.37 (5.78-7.93) h in the perineural group and 7.37 (6.10-7.97) h in the i.v. group (P=0.61). There was also no significant difference in block onset time between the three groups. CONCLUSION Dexamethasone 4 mg has no clinically relevant effect on the duration of sensory block provided by ropivacaine applied to the ulnar nerve. CLINICAL TRIAL REGISTRATION DRKS, 00014604; EudraCT, 2018-001221-98.
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Affiliation(s)
- Peter Marhofer
- Department of Anaesthesia, Intensive Care Medicine and Pain Medicine, Medical University of Vienna, Vienna, Austria.
| | - Malachy Columb
- Department of Anaesthesia, Manchester University Hospitals Foundation Trust, Wythenshawe, UK
| | - Phil M Hopkins
- Leeds Institute of Medical Research at St James's, University of Leeds, Leeds, UK
| | - Manfred Greher
- Department of Anaesthesia, Intensive Care Medicine and Pain Therapy, Herz Jesu Hospital Vienna, Vienna, Austria
| | - Daniela Marhofer
- Department of Anaesthesia, Intensive Care Medicine and Pain Medicine, Medical University of Vienna, Vienna, Austria
| | - Max Bienzle
- Department of Clinical Pharmacology, Medical University of Vienna, Vienna, Austria
| | - Markus Zeitlinger
- Department of Clinical Pharmacology, Medical University of Vienna, Vienna, Austria
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Hirtler L, Huber FA, Wlodek V. Cutaneous innervation of the distal forearm and hand — Minimizing complication rate by defining danger zones for surgical approaches. Ann Anat 2018; 220:38-50. [DOI: 10.1016/j.aanat.2018.06.007] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/29/2018] [Revised: 06/22/2018] [Accepted: 06/25/2018] [Indexed: 01/11/2023]
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Comment on ‘Cutaneous innervation of the hand: clinical testing in volunteers shows high intra- and inter-individual variability’ (Br J Anaesth 2018; 120: 836–45). Br J Anaesth 2018; 121:683-684. [DOI: 10.1016/j.bja.2018.06.010] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/18/2018] [Accepted: 06/25/2018] [Indexed: 11/17/2022] Open
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Marhofer P, Keplinger M, Moriggl B. Authors' response to a comment on ‘Cutaneous innervation of the hand: clinical testing in volunteers shows high intra- and inter-individual variability’ (Br J Anaesth 2018; 120:836–45). Br J Anaesth 2018; 121:684-685. [DOI: 10.1016/j.bja.2018.06.001] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/24/2018] [Accepted: 06/08/2018] [Indexed: 10/28/2022] Open
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