Techniques in regional anesthesia & pain management最新文献

The possibility of performing the majority of the pain-control interventions in the lumbar spine without using fluoroscopy is a very promising alternative. A clear description of the most relevant sonoanatomy of the lumbar spine and the proposal for a systematic approach to perform principal lumbar spine blocks may help those that are beginning to use ultrasound and increase the interest of professionals that normally perform these blocks with x-rays. Therefore, the structures that are easily identifiable by ultrasound from the muscular blocks and the facet joints are first described.

Portable and affordable high-resolution ultrasound (US) machines have accelerated the interest in the use of US guidance for interventional pain procedures. The advantages of ultrasonography over fluoroscopy are as follows: (1) no radiation exposure to both the patient (especially with repeated procedures) and the practitioner; (2) real-time visualization of soft tissues (nerves, muscles, tendons, and vessels); and (3) needle-tip advancement relevant to surrounding structures and local anesthetic spread. Even though the target structure is identified correctly, there is still the challenge of placing the needle tip in the optimum site. To encourage pain physicians to use US for interventional procedures, this article aims to review some basic aspects of scanning and imaging techniques.

Puncture of trigger points in myofascial syndrome can be performed with greater safety for the patient under ultrasound-guided techniques. The identification of potentially hazardous structures in the path of the needle, together with the development and validation of tools like sonoelastography, spontaneous muscle contraction (twitch response), or vascular dynamics, helps us to be more accurate, specially in cases where the trigger points are in deep fasciae or muscular layers. Ultrasound-guided interfascial block, a known regional anesthetic technique, is emerging as a promising approach with minimum traumatic damage to the muscles.

Shoulder pain is one of the common complaints to physicians in general practice. Among therapeutic measures used to treat this pain, invasive techniques, such as joints and periarticular injection, as well as suprascapular and axillary nerve block, play a crucial role. Ultrasound guidance is a safe alternative to blind techniques, increasing the safety and accuracy of the procedure and reducing complications. A good understanding of the anatomy and sonoanatomy is of paramount importance in performing the ultrasound-guided injections.

Ultrasound guidance of infiltrations in the management of chronic pain allows us to visualize in “real time” the advance of the needle and the diffusion of the analgesic agent in and around the pain-generating anatomical structures. It also enables us to avoid important structures, blood vessels, for example, located in the path of the puncture, thus, avoiding complications. The pelvic area has many pain-generating zones, including joints, muscles, and certain specific points, where nerve structures can be compressed. The involvement of these structures can produce pelvic or lower back pain along with pain that radiates to the lower limbs. Owing to its inability to penetrate bone, ultrasound is unable to visualize, and therefore infiltrate, a number of important nerves located on the anterior face of the sacrum, including the ganglion impar, inferior hypogastric plexus, and superior hypogastric plexus. In this article, we describe different techniques for the ultrasound-guided infiltration in the pelvic region, including the sacroiliac joint, pudendal nerve, coccygeal nerves, transsacral block, lateral branches of the posterior sacral roots, dorsal branch of the L5, caudal epidural infiltration, infiltration of the piriformis and gluteus medius muscles, infiltration of the iliolumbar ligament, ganglion impar block, and superior hypogastric plexus block.

Ultrasound is a particularly valuable imaging technique when performing nerve blocks at the cervical level. High-frequency probes provide high-quality resolution and are safe in skilled hands. Typically, interventions performed at the cervical level have been carried out with the help of x-rays, with the corresponding disadvantages such as the exposure to radiation and the inherent inability to observe radiotransparent structures such as blood vessels and nerves. Ultrasound allows us to visualize soft tissues and guide the tip of the needle to our target, without harming particularly delicate structures found in the path of the needle. This is important in nerve root blocks where the identification of periradicular nerves is crucial for the safety of the block itself. Likewise, ultrasound allows us to manipulate the needle with greater precision in the correct location; as is the case in cervical sympathetic nerve block where we can observe the injection of the liquid behind the prevertebral fascia and in front of the fascia of the longus colli muscle. In this article, we describe the most frequent techniques used in the pain clinic to treat headache and cervical pain, with special emphasis on the safety of the procedure.

Most routine intra-articular and extra-articular knee infiltrations performed in pain management are carried out by means of blind techniques or fluoroscopy-guided techniques. Alternatively, ultrasound-guided techniques are a safer and more precise way to perform these procedures. An extensive knowledge of knee anatomy will help us to obtain high-quality real-time ultrasound images before performing any infiltrations. In the current article, we present how to systematically examine the knee sonoanatomy and also describe the ultrasound-guided interventional basis for knee joint pain management.

Cervical radiculopathy can be a disabling condition for patients. Pain, paresthesia, and motor deficit may occur. Although there are ample treatment options for these patients, surgery may be necessary. The goal of this article is to discuss the diagnosis of cervical radiculopathy and outline surgical indications. Surgical options are discussed in detail. Anterior and posterior approaches will be reviewed along with the advantages of each. Hopefully this article enables the reader to look at cervical radiculopathy through the eyes of a surgeon and aid in determining appropriate care. Understanding the surgical anatomy may also allow a pain management specialist to focus his or her treatment directly on the offending pathology and optimize nonsurgical care, as well.

The incidence of lumbar fusion surgeries has risen exponentially over the last 2 decades. Although a very useful and necessary surgery for specific conditions, spinal fusions have undeservingly earned a negative reputation. With stringent patient selection, lumbar fusions are highly efficacious. This article is intended to inform the reader of the indications for lumbar spinal fusion and discuss conditions that potentiate successful outcomes.

Cervical spinal stenosis is a commonly encountered condition. Symptoms of radiculopathy are ameliorable to conservative measures. However, central canal stenosis in the setting of myelopathy is a disease warranting surgical intervention. To decompress the spinal cord, the canal needs to be expanded. Traditionally this can be accomplished via a laminectomy. The occurrence of postoperative deformity has led to the advent of other surgical techniques to address spinal stenosis. Both cervical laminoplasty and laminectomy with posterior fusion are available options that may prevent the progression of cervical instability or deformity or both. This article discusses the treatments available and outlines the benefits of each.