Regional Anesthesia & Pain Medicine最新文献

Introduction: The difference between the effects of peripheral nerve block (PNB) with general anesthesia (GA) and GA alone on the patients' postoperative clinical outcomes remains unknown. We assessed whether there is a difference in postoperative delirium and composite morbidity between patients receiving GA with PNB and GA alone using a national clinical database in Japan.

Methods: We compared the outcomes of patients receiving GA with PNB and GA alone from April 2016 to October 2019. The primary outcome was postoperative delirium, defined as a status requiring newly prescribed antipsychotic drugs or that given the code of a reimbursable disease after the surgery date. The secondary outcome was morbidity incidence as the occurrence of at least one of any of the following life-threatening complications. We conducted propensity score-matched analyses using covariates for patients who underwent any surgical procedure. We used instrumental variables and restricted the definition of postoperative delirium and subgroup for sensitivity analyses.

Results: Of 653,759 patients, 90,358 received GA-PNB and 563,401 received only GA. After 1:4 propensity score matching, 89,754 patients were included in the GA-PNB and 359,015 in the GA. The adjusted ORs for postoperative delirium and composite morbidity were 0.96 (95% CIs 0.94 to 0.99; p<0.01), 0.80 (95% CIs 0.76 to 0.83; p<0.001), respectively, for the GA-PNB concerning the GA. For sensitivity analyses, findings were also consistent with instrumental variables and subgroup analyses.

Discussion: This retrospective, nationwide cohort study demonstrated that GA-PNB was associated with a small reduction in the likelihood of postoperative delirium and a moderate reduction in the likelihood of composite morbidity.

Introduction: Fluoroscopic-guided radiofrequency ablation of the lumbar medial branches is commonly performed to manage chronic low back pain originating from the facet joints. A detailed understanding of the course of medial branches in relation to bony and soft tissue landmarks is paramount to optimizing lumbar denervation procedures, particularly parallel placement of the radiofrequency electrode. The objectives of this study were to investigate the relationship of medial branches to anatomical landmarks and discuss the implications for lumbar denervation.

Methods: Ten cadaveric specimens were meticulously dissected. The origin, course, and relationship of lumbar medial branches to bony and soft tissue landmarks were documented.

Results: The medial branches followed the lateral neck of superior articular process deep to the intertransversarii mediales muscle at each lumbar vertebral level. In all specimens, the medial branches coursed laterally on the anterior half of the neck and transitioned from parasagittal-to-medial on the posterior half to reach the mamillo-accessory notch. The mamillo-accessory ligament was found to not occlude the nerve on the posterior quarter of the lateral neck but rather at the mamillo-accessory notch located at the posterior margin of the superior articular process.

Discussion: A detailed understanding of the relationship of medial branches to anatomical landmarks is essential to optimizing needle placement for lumbar denervation procedures. The current study suggests that a parasagittal placement, with increased cranial-to-caudal angulation of the electrode, may improve parallel tip alignment with the targeted medial branch and represent a potential alternative to the traditional technique.

Background: The fluoroscopic-guided epidural access is occasionally challenging; therefore, the contralateral oblique (CLO) view has emerged as an alternative approach. The CLO view appears to be optimal for mid-thoracic epidural access; however, evidence on its utility is lacking. Therefore, we aimed to evaluate the clinical usefulness of the CLO view at 60°±5° compared with the lateral (LAT) view using fluoroscopic-guided mid-thoracic epidural access.

Methods: Patients were randomly allocated to undergo mid-thoracic epidural access under the fluoroscopic LAT view (LAT group) or CLO view (CLO group). The primary outcome was the first-pass success rate of mid-thoracic epidural access. The secondary outcomes were procedural pain intensity, patient satisfaction, needling time, number of needle passes, and radiation dose.

Results: Seventy-nine patients were included. The first-pass success rate was significantly higher in the CLO group than in the LAT group (68.3% vs 34.2%, difference: 34.1%; 95% CI 13.3 to 54.8; p=0.003). Procedural pain intensity was significantly lower in the CLO group than in the LAT group. Patient satisfaction was significantly greater in the CLO group than in the LAT group. The needling time and the number of needle passes were significantly lower in the CLO group than in the LAT group. Radiation dose in the CLO group was significantly reduced compared with that in the LAT group.

Conclusions: The fluoroscopic CLO view at 60°±5° increased the success rate and patient satisfaction and reduced the procedural time and patient discomfort compared with the LAT view when performing mid-thoracic epidural access. Therefore, the CLO view at 60°±5° can be considered for mid-thoracic epidural access under fluoroscopic guidance.

Trial registration number: KCT0004926.