Catter Perineural

Trminos de Bsqueda
!! Perineural
!! 208

catheter (No Mesh)

trminos de bsqueda

!! Nerve
!! 31

block [MESH] and Chronic Pain [Mesh]

trminos de bsqueda

!! Perineural

Catheter Techniques

International Anesthesiology Clinics. Vol 48, No. 4. 71-84

!! Proveer

analgesia sostenida ms all de la duracin de un bloqueo perifrico de inyeccin nica

!! Reduccin !! Mayor

consumo de opioides

satisfaccin paciente temprana

!! Rehabilitacin !! Pacientes

tolerante a opioides

Complicaciones
!! Infeccin
!!
!! 3%.

localizada

Capdevilla. 1416 pcts.

Remocin de catter !! 1 caso de absceso del Psoas

!! Hematoma
!!

Compresin nerviosa
!! Raro

!! Insercin

incorrecta. Migracin

and the patient had not experienced phantom sensations for 48 hours, the infusion was effectwas of mental imagery. Brain 2008;131:218191 Center, Abano Terme, Italy; Department of Anesthesia, Ce-the catheter permanently discontinued and removed. Morey TE, Giannoni J, Duncan Enneking dars Sinai Medical Center, RESULTS: Los Angeles, California; #Pain Median duration of the 18. local anesthetic infusion was E, 30Scarborough days (95%MT, condence FK. Nerve sheath catheter analgesia after amputation. Clin Therapy and Palliative Care Unit, Hospital of Rimini, Rimini; interval, 2530 days). On postoperative day 1, 73% of the patients complained of severe-toOrthop Relat Res 2002;397:2819 and Fourth Ward of Oncologic OrthopedicTrauma Surgery, intolerable pain (visual analog scale 2). However, the incidence of severe-to-intolerable 19. Lakshmi M, Scott S, Robert B. The efficacy of postoperative phantomItaly. limb pain was only 3% at the end of the infusion 12-month period. At the end the Rizzoli Orthopedic Institute, Bologna, perineural of evaluation bupivacaine and clonidine afterof lower 12-month period, the percentage of patients with VRS pain scores were 0 84%, 1 10%, 2 extremity amputation in preventing phantom limb pain and 3%, 3 3%, and 4 none. However, phantom limbJ sensations present stump pain. Clin Anesth were 2007;19:226 9 in 39% of patients RECUSE NOTE at the end of the 12-month evaluation All patients able to manage P. the elastomeric 20. period. Jensen TS, Krebs B, were Nielsen J, Rasmussen Immediate and Paul F. White is section Editor of Book, Multimedia catheter infusion system atand home. long-term phantom limb pain in amputees: incidence, clinical Meeting Reviews for the Journal. The manuscript characteristics and relationship to ropivacaine pre-amputation pain. Pain CONCLUSION: Usewas of ahandled prolonged postoperative perineural infusion of 0.5% seems by Spencer S. Liu, section Editor of Pain Medicine, andfor Dr. 1985;21:26778 to be an effective therapy the treatment of phantom limb pain and sensations after lower 21. Bach S, Noreng15) MF, Tjellden NU. Phantom limb pain in White was not involved in any way with the editorial(Anesth process Analg extremity amputation. 2010;111:1308 amputees during the first 12 months following limb amputaor decision.

tion, after preoperative lumbar epidural blockade. Pain 1988;33:297301 phantom sensations, which are CH. resistant to frequently used 22. Jahangiri M, Jayatunga AP, Bradley JW, Dark Prevention ACKNOWLEDGMENTShantom limb syndrome (PLS) is a postamputation 3,13,14 analgesic and psychotropic drugs. Several different syndrome that is characterized by pain in the stump, of phantom pain after major lower limb amputation by epiThe authors thank Elettra Pignotti for assistance with the statisti1 4 dural infusion of diamorphine, clonidine and bupivacaine. treatment approaches have been used to reduce phantom phantom limb pain, and phantom sensations. The cal analysis, and Keith Smith for assistance with the translation of Ann R Coll limb Surg pain, Engl 1994;76:324 6 including surgical, medical, physical, and behavincidence of this syndrome varies from 30% to 90%, with an the manuscript. 23. Katsuly-Liapis I, Georgakis P, Tierry C. Preemptive extradural ioral therapy strategies, but the results have been disaponset in the early postoperative period in 75% of the reduces analgesia the incidence of phantom pain in lower limb 13,5,6 pointing. Therefore, the search for more effective therapies and an average duration of 7 years afteramputees limb [abstract]. Br J Anaesth 1996;76:125 REFERENCES cases 7 continues, but has proven to regional be challenging 24. Katz J. Prevention of phantom limb pain by anaesthe-because of the amputation. Risk factors include preamputation pain 1. Halbert J, Crotty M, Cameron ID. Evidence for the optimal sia. Lancet 1997;349:519 20 of amputations, and the differing reasons for varying types management of acute and phantom a systematic (especially inchronic patients withpain: vascular damage),8 loss of 25. Gehling M, performing Tryba M. Prophylaxis of phantom pain: is regional review. Clin J Pain 2002;18:84 operation. dominant upper92 limb, bilateral amputation, loweranalgesia limb ineffective? [in the German] Schmerz 2003;17:119 2. Manchikanti L, Singh V. Managing phantom pain. Pain PhyThe purpose of this prospective study was to evaluate amputation, proximal amputation, the presence 26. of stump Nikolajsen L, Ilkjaer S, Christensen JH, Krner K, Jensen TS. sician 2004;7:36575 5,9 12 the effectiveness of a prolonged perineural and TS. depression. Randomised trial of epidural bupivacaine and morphine in infusion of a 3. Nikolajsen pain, L, Jensen Phantom limb pain. Br J Anaesth concentration of pain a local anestheticampuas an alternative to prevention high of stump and phantom in lower-limb 2001;87:10716 It has been suggested that changes in the peripheral patient-controlled tation. Lancet 1997;350:13537 analgesia (PCA) with morphine for the 4. Woodhousenervous A. Phantom limb sensation. Clin Exp Pharmacol system after nerve transection are produced by 27. Nikolajsen prevention L, Ilkjaer S,of Jensen TS.phantom Effect of limb preoperative Physiol 2005;32:132 4 chronic pain in patients unnoxious input into the spinal cord, leading to extradural bupivacaine and morphine on stump sensation in 5. Richardson ongoing C, Glenn S, Nurmikko T, Horgan M. Incidence of dergoing lower limb amputations. central sensitization with persistent pain andlimb amputees. Br J Anaesth 1998;81:348 54 lower phantom phenomena including phantom limb painpostoperative 6 months 28. Sun T, Sacan O, White PF, Coleman J, Rohrich RJ, Kenkel JM. after major lower limb amputation in patients with peripheral Perioperative vs. postoperative celecoxib on patient outvascular disease. Clin J Pain 2006;22:353 8 end of the article. Authors affiliations are listed at the comes afterMETHODS major plastic surgery procedures. Anesth Analg 6. Steffen P. Phantom limb pain [in German]. Anasthesiol IntenAccepted for publication June 10, 2010. This 2008;106:950 8 prospective study was approved by the ethical comsivmed Notfallmed Schmerzther 2006;41:378 86 Disclosure: The authors report no conflicts of interest. Battista Borghi, MD, Marco DAddabbo, MD,* F. MD, PhD, Pina Gallerani, RN, Battista Borghi, MD, Marco DAddabbo, MD,* Paul F.White, White, MD, PhD, Pina Gallerani, RN, mittee at the Istituto Ortopedico Rizzoli in Bologna, Italy. 29. Fisher A,Paul Meller Y. Continuous postoperative regional analge7. Rajbhandari SM, Jarett JA, Griffiths PD, Ward JD. Diabetic Address and reprint requests to Paul F. White, MD,# MD, PhD, sia by Andrea nerve sheath block for amputation surgery: pilot MD, study. neuropathic pain incorrespondence aToccaceli, leg amputated 44 years previously. Pain The IRB approval was given for aa randomized, prospective, Letizia Toccaceli, MD, William Raffaeli, MD,# Andrea Tognu ` , MD, Nicola Fabbri, MD, Letizia MD, William Raffaeli, Tognu ` , MD, Nicola Fabbri, 144 Ashby Lane, Los Altos, CA 94022. Address e-mail to paul.white@ Anesth Analg 1991;72:300 3 1999;83:6279 double-blind study comparing the efficacy of PCA mor-

The The Use Use of of Prolonged Prolonged Peripheral Peripheral Neural Neural Blockade Blockade After After Lower Lower Extremity Extremity Amputation: Amputation: The The Effect Effect on on Symptoms Symptoms Associated Associated with with Phantom Phantom Limb Limb Syndrome Syndrome
andMario MarioMercuri, Mercuri, MD and MD policlinicoabano.it and whitemountaininstitute@hotmail.com.
Copyright 2010 International Anesthesia Research Society
DOI: 10.1213/ANE.0b013e3181f4e848

1314

phine therapy with a continuous perineural infusion of local anesthetic. All the patients signed an IRB-approved www.anesthesia-analgesia.org ANESTHESIA & ANALGESIA BACKGROUND: Phantom limb syndrome (PLS) iscommon commonafter after limb amputations, involving up BACKGROUND: Phantom limb syndrome (PLS) is limb amputations, involving up to90% 90%of ofamputees. amputees.Although Althoughmany manydifferent differenttherapies therapieshave havebeen beenevaluated, evaluated,none nonehas has been to been 1308 www.anesthesia-analgesia.org November 2010 Volume 111 Number 5 found to to be be highly highlyeffective. effective.Therefore, Therefore,we weevaluated evaluatedthe theefcacy efcacy ofaaprolonged prolonged perineural found of perineural infusionof ofaahigh highconcentration concentrationof oflocal localanesthetic anestheticsolution solutionin inpreventing preventing PLS. infusion PLS. METHODS:AAperineural perineural catheter was placed immediately before or during surgery in 71 patients METHODS: catheter was placed immediately before or during surgery in 71 patients undergoing lower extremity amputation. A continuous infusion of 0.5% ropivacaine was started undergoing lower extremity amputation. A continuous infusion of 0.5% ropivacaine was started intraoperativelyat at55mL/h mL/h using an elastomeric (nonelectronic) pump, and continued for to 83 intraoperatively using an elastomeric (nonelectronic) pump, and continued for 44 to 83 days after surgery. PLS was evaluated on the rst postoperative day and then 1, 2, 3, and days after surgery. PLS was evaluated on the rst postoperative day and then 1, 2, 3, and 44 weeks, and 3, 6, 9, and 12 months after surgery. To evaluate the presence and severity of PLS weeks, and 3, 6, 9, and 12 months after surgery. To evaluate the presence and severity of PLS while the patient was receiving the ropivacaine infusion, it was discontinued for 6 to 12 hours while the patient was receiving the ropivacaine infusion, it was discontinued for 6 to 12 hours before each assessment period (i.e., until the sensation in the extremity returned). The severity before each assessment period (i.e., until the sensation in5-point the extremity The severity of phantom limb and stump pain was assessed using a verbal returned). rating scale (VRS), with of phantom limb and stump pain was assessed using a 5-point verbal rating scale (VRS), with 0 no pain to 4 intolerable pain, and phantom sensations were recorded as present or

Inclusin
!! Oncolgico

(n=42) !! Traumtico (n=14) !! Isqumico (n=2) !! Revisin mun (n=4)

!! Inicialmente

aleatorizado con bomba PCA morfina

Distribucin quirrgica
!! Amputacin
!!

debajo de la rodilla (n=31)

Citico (n=25) !! Citico y femoral (n=6)

!! Amputacin
!!

encima de la rodilla (n=25)

Combinada

!! Amputacin !! Amputacin

(n=2)
!!

pie

(n=4)
!!

cadera

Citico

Bloqueo citico y plexo lumbar posterior

!! Medicaciones

analgsicas no opioides
!! Ketoprofeno,

!! Dolor !! Dolor

mun

Ibuprofeno !! Tramadol !! Oxicodona

miembro fantasma

!! Sensacin

miembro fantasma

!! Cada

7 das, suspensin por 6 a 12 horas de dolor mun, dolor miembro fantasma y sensacin fantasma

!! Retiro

!! Valoracin

catter dolor EVN (0-4) 1 o menor por 48 horas sin sensacin fantasma a los 3,6,9 y 12 meses

!! Seguimiento

Dolor crnico. Reportes de casos

Effect of Prolonged Perineural Block on Phantom Limb Symptoms

Figure 1. Number of patients (Pts) and percentages of patients with moderateto-intolerable phantom pain (verbal rating scale [VRS] score 1), and number of patients and percentage receiving perineural continuous infusion of ropivacaine 0.5% at each of the postoperative assessment periods.

were contacted by telephone at weekly-to-monthly intervals for up to 1 year after surgery to inquire about the severity of their stump pain and phantom limb symptoms, as well as to document the status of the perineural catheter system. All continuous data are expressed in terms of median and 95% confidence intervals. All values were rounded off

ischemia, with a sciatic nerve block. Finally, 4 patients underwent complete hip amputations for bone cancer in the femur with posterior lumbar plexus and sciatic nerve blocks. The median duration of the infusion for the 62 patients who completed the study was 30 days (2530 days) (with a minimum to maximum range from 4 to 83 days [Fig. 1]). In

!! Nueve

muerte antes de completar seguimiento de los pacientes con protocolo completo tuvo recurrencia de dolor fantasma

!!

Scores altos
!! !!

Desalojamiento accidental (n=1) Migracin de catter (n=1) Reaccin local adversa remocin catter (n=1) Retiro por no tolerancia por parte del paciente (n=1)

!! Ninguno

!!

Scores moderados
!!

!!

Table 1. 1. The The Intensity Intensity of of Stump Stump Pain Pain at at the the Various Various Postoperative Postoperative Assessment Assessment Periods Periods After After the the Table Amputation Procedure Was Recorded Using a 5-Point Verbal Rating Scale Amputation Procedure Was Recorded Using a 5-Point Verbal Rating Scale
Assessment intervals intervals Assessment 1 d 1d 1 wk wk 1 2 wk 2 wk 3 wk wk 3 4 wk wk 4 5 wk wk 5 3 mo mo 3 6 mo 6 mo 9 mo mo 9 12 mo mo 12 0 0 0 0 8 (13%) (13%) 8 40 (65%) (65%) 40 48 (77%) (77%) 48 54 (87%) (87%) 54 56 (90%) (90%) 56 59 (95%) (95%) 59 60 (97%) (97%) 60 60 (97%) (97%) 60 60 (97%) (97%) 60 1 1 0 0 16 (26%) (26%) 16 20 (32%) (32%) 20 13 (21%) (21%) 13 7 (11%) (11%) 7 6 (10%) (10%) 6 3 (5%) (5%) 3 2 (3%) 2 (3%) 2 (3%) (3%) 2 2 (3%) (3%) 2
a Verbal rating rating scale scale score scorea Verbal 2 2 6 (10%) 6 (10%) 32 (52%) (52%) 32 2 (3%) 2 (3%) 1 (2%) (2%) 1 1 (2%) (2%) 1 0 0 0 0 0 0 0 0 0 0

!!

3 3 47 (76%) 47 (76%) 6 (10%) (10%) 6 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0

4 4 9 (14%) 9 (14%) 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0

Median (95% (95% CI) CI) Median 3 (33) 3 (33) 2 (12) (12) 2 0 (00) 0 (00) 0 (00) (00) 0 0 (00) (00) 0 0 (00) (00) 0 0 (00) (00) 0 0 (00) (00) 0 0 (00) (00) 0 0 (00) (00) 0

Data are are n n (%) (%) or or median median (95% (95% condence condence interval interval CI CI ). ). The The numbers numbers of of patients patients (and (and percentages) percentages) are are listed listed at at each each of of the the assessment assessment intervals. intervals. Data a a Verbal rating scale scores are as follows: 0 no pain; 1 mild pain; 2 moderate pain; 3 severe pain; and 4 intolerable pain. Verbal rating scale scores are as follows: 0 no pain; 1 mild pain; 2 moderate pain; 3 severe pain; and 4 intolerable pain.

Table 2. 2. The The Intensity Intensity of of Phantom Phantom Limb Limb Pain Pain at at Various Various Assessment Assessment Periods Periods After After Amputation Amputation Procedure Procedure Table Using a a 5-Point 5-Point Verbal Verbal Rating Rating Scale Scale Using
a Verbal rating rating scale scale score scorea Verbal

Assessment intervals intervals Assessment 1d d 1 1 wk wk 1 2 wk wk 2 3 wk wk 3 4 wk wk 4 5 wk wk 5 3 mo mo 3 6 mo mo 6 9 mo mo 9 12 mo mo 12

0 0 0 0 11 (18%) (18%) 11 19 (31%) (31%) 19 29 (47%) (47%) 29 40 (65%) (65%) 40 46 (74%) (74%) 46 48 (79%) (79%) 48 51 (82%) (82%) 51 52 (84%) (84%) 52 52 (84%) (84%) 52

1 1 4 (6%) (6%) 4 13 (21%) (21%) 13 13 (21%) (21%) 13 18 (29%) (29%) 18 12 (19%) (19%) 12 10 (16%) (16%) 10 8 (13%) (13%) 8 7 (11%) (11%) 7 6 (10%) (10%) 6 6 (10%) (10%) 6

2 2 13 (21%) (21%) 13 15 (24%) (24%) 15 17 (27%) (27%) 17 9 (15%) (15%) 9 7 (11%) (11%) 7 4 (7%) (7%) 4 3 (5%) (5%) 3 2 (3%) (3%) 2 2 (3%) (3%) 2 2 (3%) (3%) 2

3 3 36 (58%) (58%) 36 19 (31%) (31%) 19 13 (21%) (21%) 13 6 (10%) (10%) 6 3 (5%) (5%) 3 2 (3%) (3%) 2 2 (3%) (3%) 2 2 (3%) (3%) 2 2 (3%) (3%) 2 2 (3%) (3%) 2

4 4 9 (15%) (15%) 9 4 (6%) (6%) 4 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0

Median (95% (95% CI) CI) Median 3 (33) (33) 3 2 (13) (13) 2 1 (12) (12) 1 1 (01) (01) 1 0 (00) (00) 0 0 (00) (00) 0 0 (00) (00) 0 0 (00) (00) 0 0 (00) (00) 0 0 (00) (00) 0

Data are are n n (%) (%) or or median median (95% (95% condence condence interval interval CI CI ). ). The The numbers numbers of of patients patients (and (and percentages) percentages) at at each each pain pain severity severity level level during during the the 12-mo 12-mo follow-up follow-up period period Data are listed. listed. are a a Verbal rating rating scale scale scores scores are are as as follows: follows: 0 0 no no pain; pain; 1 1 mild mild pain; pain; 2 2 moderate moderate pain; pain; 3 3 severe severe pain; pain; and and 4 4 intolerable intolerable pain. pain. Verbal

tramadol ( (n n 16), 16), and and oxycodone oxycodone ( (n n 5). 5). No No differences differences tramadol were observed observed among among oncologic, oncologic, ischemic, ischemic, trauma, trauma, or or were revision stump patients. One of the catheters was acciden-

Table 2. 2. After After the the first first week week of of treatment, treatment, a a majority majority of of the the Table patients reported reported phantom phantom pain pain VRS VRS scores scores of of 2, 2, 3, 3, or or 4. 4. patients 10% However, by the fifth week of treatment, fewer than 10%

The purpose of the case is to report the clinical value of the ultrasound-guided tinuous posterior approach the brachial infusion of to a local anesthetic in a patient where standard landmark-based n plexus in the treatment of phantom limb syndrome after an upper extremity amputation. Th e author experienced of a continuous perineural block was not possible. (Minerva Anestesiol 2012;78:105ultrasound guidance as sole technique to localize the brachial plexus for the purpose of placing a catheter for conKey words: Brachialfor plexus - Phantom limb syndrome - Amputation - Upper extrem tinuous infusion of a local anesthetic in a patient where standard landmark-based nerve stimulation placement Anno: 2012 Lavoro: of a continuous perineural block was not possible. (Minerva Anestesiol 2012;78:105-8) Mese: January titolo breve: ULTRASOUND-GUIDED POSTERIOR APPROACH TO BRACHIAL Volume: 78 PLEXUS IN UPPER PHANTOM LIMB SYNDROME Key words: Brachial plexus - Phantom limb syndrome - Amputation - Upper extremity.
No: 1 Rivista: MINERVA ANESTESIOLOGICA Cod Rivista: Minerva Anestesiol

Ultrasound-guided posterior approach to brachial plexus for the treatment of Ultrasound-guided posterior approach to brachial plexus for the treatment of upper phantom limb syndrome upper phantom limb syndrome
1 2 3 4, 5, 6
1Unit

he use of a prolonged perineural blockade with a high concentration (0.5%) of ropivacaine has been reported to markedly attenuate postoperative phantom limb pain and sensations after lower limb amputation.1, 2 Therefore, we evaluated the use of a prolonged continuous perineural block technique with 0.5% ropivacaine in a patient undergoing an interscapulothoracic amputation of an upper extremity using the posterior approach to the brachial plexus as recently described by Mariano et al.3 and Antonakis et al.4 for perioperative pain management in patient undergoing major shoulder surgery. This Case Report demonstrates the clinical use of the ultrasound-guided posterior approach to the brachial plexus in the treatment of phantom limb syndrome after an upper extremity amputation.

C A S E R E P O RT

he use of a prolonged perineural blockade with a high concentration (0.5%) of ropiCase report vacaine has been reported to markedly attenuA 46-year-oldate woman with recurrent osteosarcoma postoperative phantom limb pain and sensawithout metastases, underwent an interscapulo-thoracic 1, 2 tions lower limb under amputation. Therefore, amputation of her leftafter upper extremity general anesthesia. She complained of severe upper pain we evaluated the use of limb a prolonged continuand other sensations consistent with the phantom limb ous perineural block technique with 0.5% syndrome in the early postoperative period despite the ropivacaine in a patient an intercontinuous infusion of 0.5% ropivacaine infusedundergoing at 5 ml/ hr through a perineural catheter placed intraoperatively scapulothoracic amputation of an upper extremby the surgeon adjacent to the transected nerve (over a ityminimize using the posterior approach to the brachial distance of C 4 cm theR risk A Sto E REPO T of catheter dislocaplexus as recently described by Mariano et al.3 tion), immediately prior to surgical closure and then it was tunneled to the surface and sutured skin. As part 4 for and Antonakis et to al.the perioperative pain manof the patients postoperative multimodal analgesic regiagement in patient undergoing major shoulder men,5 the continuous perineural local anesthetic infusion was supplemented with ketoprofen, 100 mg IV every 8 h, surgery. This Case Report demonstrates the clingabapentin 600 mg po TID, and patient-controlled analical use of the ultrasound-guided posterior apgesia with IV morphine. Despite this aggressive analgesic proach to the of brachial plexus in on the treatment of regimen, the patient complained a pain score of 10 an 11-point verbal rating scale (VRS), with 0=no pain to upper extremphantom limb syndrome after an 10=worst pain imaginable. Although the concentration of ity was amputation. the local anesthetic increased to 0.75% and supple-

primo autore: TOGN pagine: 105-8

A 46-year-old wom without metastases, un amputation of her left anesthesia. She compla and other sensations co syndrome in the early continuous infusion of hr through a perineura by the surgeon adjacen distance of 4 cm to min tion), immediately prior tunneled to the surface of the patients postope men,5 the continuous p was supplemented with gabapentin 600 mg po gesia with IV morphine regimen, the patient co an 11-point verbal ratin 10=worst pain imaginab the local anesthetic was

, B. BORGHI , S. 3 GULLOTTA , P. F. WHITE 1 , B. BORGHIA. 2TOGN 4, 5, 6 A. TOGN , S. GULLOTTA , P. F. WHITE 105 Vol. 78 - No. 1 MINERVA ANESTESIOLOGICA Vol. 78 - No. 1 MINERVA ANESTESIOLOGICA
of Anesthesia and Intensive Care, Rizzoli Orthopedic Institute, Bologna, Italy; 2Department of Surgery and Anesthesiology Sciences, University of Bologna; Research Unit of Anesthesia and Intensive Care, Rizzoli Orthopedic , Institute, Bologna, Italy; 3Department of Anesthesia,, Citt di Quartu Policlinic,2 Cagliari, Italy; 4Director of Research, Policlinico Abano, Abano Terme, Padua, Italy, 5Visiting Professor University of Bologna and Rizzoli Orthopedic Institute, Bologna, Italy; 6Clinical Research, Cedars Sinai Medical Center, Los Angeles, CA, USA

1Unit

of Anesthesia and Intensive Care Rizzoli Orthopedic Institute Bologna, Italy; Department of Surgery and Anesthesiology Sciences, University of Bologna; Research Unit of Anesthesia and Intensive Care, Rizzoli Orthopedic Institute, Bologna, Italy; 3Department of Anesthesia, Citt di Quartu Policlinic, Cagliari, Italy; 4Director of Research, Policlinico Abano, Abano Terme, Padua, Italy, 5Visiting Professor University of Bologna and Rizzoli Orthopedic ABST R A Angeles, CT Institute, Bologna, Italy; 6Clinical Research, Cedars Sinai Medical Center, Los CA, USA
The purpose of the case is to report the clinical value of the ultrasound-guided posterior approach to the brachial plexus in the treatment of phantom limb syndrome after an upper extremity amputation. The author experienced ultrasound guidance as sole technique to localize the brachial plexus for the purpose of placing a catheter for continuous infusion of a local anesthetic in a patient where standard landmark-based nerve stimulation for placement of a continuous perineural block was not possible. (Minerva Anestesiol 2012;78:105-8) Key words: Brachial plexus - Phantom limb syndrome - Amputation - Upper extremity.

ABSTRACT

hesia and Pain Medicine

Tcnica de Mariano

&

Volume 34, Number 1, January-February 2009 Ultrasound-Guided Posterior Intersc

The patient is placed in the right lateral decubitus position. The junction of the levator scapulae and trapezius he BV.[ B, A 17-gauge Tuohy-tip needle is directed under in-plane ultrasound guidance through the middle scal achial plexus.

ultrasound guidance. With the bevel directed caudad and lateral, an 8.89 cm, 17-gauge, insulated Tuohy-tip needle (Stimucath, Arrow International, Reading, PA) was inserted through the lidocaine skin wheal. The needle was connected to a nerve stimulator (Stimuplex-DIG; B. Braun Medical, Bethlehem, PA) initially set at 1.2 mA, 0.1 ms, and 2 Hz.

scalene muscles (Fig. 1B). Deltoid and biceps motion were sought and elicited at a current of 0.6 mA on the rst attempt. A 19-gauge catheter was then placed through the length of the needle, and the nerve stimulator lead transferred from the needle to the catheter, which has a conducting wire through its length delivering current to its tip. The stimulating current

ND - GUIDED POSTERIOR APPROACH TO BRACHIAL PLEXUS IN UPPER PHANTOM LIMB SYNDROME

Catter abordaje Posterior

A) On this ultrasound view, the arrow heads point out the path of the perineural catheter; the circles point out nerve roots; and B) photo showing posterior-lateral view of patient with final placement of the perineural cathe ation procedure.

Resultados
!! EVN

>7 en postoperatorio primeras 48 horas

PCA opioide !! Gabapentina 600 mg
!!

!! Infusin

descontinuada al final de la 4 semana fantasma ausente al final del seguimiento

!!

!! Sensacin

!! EVN
!!

3 postcatter

No requerimiento opioide

3 meses

Acta Anaesthesiol Scand 2011; 55: 242247 Printed in Singapore. All rights reserved

r 2011 The Authors Journal compilation r 2011 The Acta Anaesthesiologica Scandinavica Foundation ACTA ANAESTHESIOLOGICA SCANDINAVICA

doi: 10.1111/j.1399-6576.2010.02370.x
Acta Anaesthesiol Scand 2011; 55: 242247 Printed in Singapore. All rights reserved

r 2011 The Authors Journal compilation r 2011 The Acta Anaesthesiologica Scandinavic

Case Report

ACTA ANAESTHESIOLOGICA SCANDINAVICA

doi: 10.1111/j.1399-6576.2010.02370.x

Ultrasound-guided continuous suprascapular nerve block for adhesive capsulitis: one continuous case and a short Ultrasound-guided suprascapular nerve topical review block for adhesive capsulitis: one case and a short
topical review
3 Acta Anaesthesiol J. BRGLUM , A. BARTHOLDY , H. HAUTOPP2, M. R. KROGSGAARD and K. JENSEN1Scand 2011; 55: 242247 1 2 Printed Bispebjerg, in2 Singapore. All rights reserved Department of Anaesthesia and Intensive Care, Copenhagen University Denmark, Backand Rehabilitation Centre, 1 1 Hospital, 3 1 1 1

Case R

J. BRGLUM , A. BARTHOLDY , H. HAUTOPP , M. R. KROGSGAARD and K. JENSEN Copenhagen, Denmark and 3Department 1of Orthopaedic Surgery, Copenhagen University Hospital, Bispebjerg, Denmark Department of Anaesthesia and Intensive Care, Copenhagen University Hospital, Bispebjerg, Denmark, 2Back- and Rehabilitation
Copenhagen, Denmark and 3Department of Orthopaedic Surgery, Copenhagen University Hospital, Bispebjerg, Denmark

siotherapist for three consecutive weeks. This case and a We present a case with an ultrasound-guided (USG) placesiotherapist for block three consecutive We present a case with an ultrasound-guided (USG) placeshort topical review on the use of SSN in painfulweeks. This ca ment of a perineural catheter beneath the transverse scapshort topical review on the of SSN block in ment of a perineural catheter beneath the transverse scapshoulder conditions highlight the possibility of a use USG ular ligament in the scapular notch to provide a continuous shoulder conditions highlight the possibility o ular ligament in the scapular notch to provide a continuous continuous nerve block of the SSN as sufcient pain block of the suprascapular nerve (SSN). The patient sufcontinuous nerve block of the SSN as sufci block of the suprascapular nerve (SSN). The patient sufmanagement in the immediate post-operative period folfered from a severe and very painful adhesive capsulitis of management in the immediate post-operative pe fered from a severe and very painful adhesive capsulitis of capsular release shoulder. Findings other the left shoulder secondary to an the operation in the same to lowing lowing capsular release ofin the shoulder. Findings left shoulder secondary an operation in the same of the painful shoulder conditions and shoulder suggestions for future shoulder conducted 20 weeks previously for impingement painful conditions and suggestions fo shoulder conducted 20 weeks previously for impingement syndrome and a superior anteriorposterior tear. studies are discussed in thestudies text. are discussed in the text. syndrome and a superior labral anteriorposterior tear. labral new operation with capsular release, the Following a new operation with Following capsular a release, the Accepted for publication 21 November 2010 Accepted for publication November 2010 placement of a continuous nerve block catheter 21 subseplacement of a continuous nerve block catheter subsequently allowed for nearly pain-free low impact passive r 2011 The Authors quently allowed for nearly pain-free low impact passive rby 2011 Theperforming Authors Journal compilation r 2011 The Acta Anaesthesiologica Scandinavica and guided active mobilization the phyJournal compilation r 2011 The Acta Anaesthesiologica Scandinavica Foundation and guided active mobilization by the performing phy-

Case

Ultrasound-guided contin block for adhesive capsu topical review

shoulder was manifest and diagnosed by th

Patologa

Ultrasound-guided suprascapular nerve block

ed at the lateral of the transducer and !!end Avulsin parte superior under real-time labrum US guidance in a steep Glenoideo he transducer from the lateral insertion ards the inferior-medial endpoint below !! Resinsercin 8 meses n the scapular notch. A bolus of 5 ml despus e 2 mg/ml was rst administered !! Osteotoma clavicular he needle before the catheter was adm past the tip of the needle. When the !! 12 placement semanas s retracted, correct of the ca!! Hombro congelado was conrmed under US guidance when te of 1 ml ropivacaine 2 mg/ml could be pand beneath! the TSL. The rst catheter ! 20 semanas for a continuous ! block of the SSN for 10 ! Liberacin capsular e days, and was only disrupted on day artroscpica he catheter was unintentionally displaced Fig. 1. Model photo: ultrasound transducer and needle orientation the subscribed low-impact passive and for the ultrasound-guided placement of a catheter providing for tive mobilization by the physiotherapist. continuous blockage of the suprascapular nerve. The transducer is n (VAS 5 7) and discomfort quickly manplaced parallel to the scapular spine. The recommended needle

Evolucin
!! Desalojamiento

J. Brglum et al.
80
Range of motion (degrees)

catter dia 11
!!

70 60 50 40 30 20 10 0 0

EVN nuevamente a 7

Lateral

SC TM NE

Medial

!! Colocacin

catter
!!

nuevo

TSL

SPM

Dolor EVN 7 slo cuando se termina infusin de la elastomrica

Fig. 3. Transverse view of the suprascapular fossa and scapular notch roofed by the transverse scapular ligament (TSL). The tip of the needle (NE) has been placed below the TSL. Trapezius muscle (TM), subcutaneous tissue (SC), supraspinatus muscle (SPM).

Fig. 5. Develo Continuous l internal rotati 11, the second discontinued

Table 1

Motor abilities rst post-ope

Modied Bart

In the past 24 Take care of Take a showe

Evolucin
J. Brglum et al.
Range of motion (degrees)

!! Remocin
Lateral SC TM

da 22 !! Pudo continuar su terapia sin dolor

Medial NE TSL SPM

80 70 60 50 40 30 20 10 0 0 5 10 15 20 Day of measurement 25 30

Fig. 5. Development in range of motion pre- and post-operatively. Continuous line, passive external rotation; dotted line, passive internal rotation. On day 0, the patient had the operation. On day 11, the second perineural catheter was inserted; the catheter was discontinued on day 22.

Table 1 Fig. 3. Transverse view of the suprascapular fossa and scapular notch roofed by the transverse scapular ligament (TSL). The tip of the needle (NE) has been placed below the TSL. Trapezius muscle
Motor abilities in daily living during suprascapular block on the rst post-operative day. Modied Barthel index/100 95%