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  1. Article ; Online: Deep parasternal intercostal plane nerve block: an anatomical study.

    Harbell, Monica W / Langley, Natalie R / Seamans, David P / Kraus, Molly B / Carey, Frederick J / Craner, Ryan C

    Regional anesthesia and pain medicine

    2024  Volume 49, Issue 3, Page(s) 179–183

    Abstract: Introduction: The superficial and deep parasternal intercostal plane (DPIP) blocks are two new blocks for thoracic pain. There are limited cadaveric studies evaluating the dye spread with these blocks. In this study, we examined the dye spread of an ... ...

    Abstract Introduction: The superficial and deep parasternal intercostal plane (DPIP) blocks are two new blocks for thoracic pain. There are limited cadaveric studies evaluating the dye spread with these blocks. In this study, we examined the dye spread of an ultrasound-guided DPIP block in a human cadaveric model.
    Methods: Five ultrasound-guided DPIP blocks were performed in four unembalmed human cadavers using an in-plane approach with a linear transducer oriented in a transverse plane adjacent to the sternum. Twenty milliliters of 0.1% methylene blue were injected between ribs 3 and 4 into the plane deep to the internal intercostal muscles and superficial to the transversus thoracis muscle layer. The chest muscles were dissected, and the extent of dye spread was documented in both cephalocaudal and mediolateral directions.
    Results: The transversus thoracis muscle slips were stained in all cadavers from 4 to 6 levels. Intercostal nerves were dyed in all specimens. Four levels of intercostal nerves were dyed in each specimen with variability in number of levels stained above and below the level of the injection.
    Conclusions: The DPIP block spreads along the tissue plane above the transversus thoracis muscles to multiple levels to dye the intercostal nerves in this cadaver study. This block may be of clinical value for analgesia in anterior thoracic surgical procedures.
    MeSH term(s) Humans ; Nerve Block/methods ; Intercostal Nerves/diagnostic imaging ; Ultrasonography ; Cadaver ; Ultrasonography, Interventional/methods ; Iopanoic Acid/analogs & derivatives
    Chemical Substances 1,3-dihydroxypropan-2-one 1,3-diiopanoate ; Iopanoic Acid (FE9794P71J)
    Language English
    Publishing date 2024-03-04
    Publishing country England
    Document type Journal Article
    ZDB-ID 1425299-5
    ISSN 1532-8651 ; 1098-7339 ; 0146-521X
    ISSN (online) 1532-8651
    ISSN 1098-7339 ; 0146-521X
    DOI 10.1136/rapm-2023-104716
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  2. Article ; Online: Evaluating two approaches to the erector spinae plane block: an anatomical study.

    Harbell, Monica W / Langley, Natalie R / Seamans, David P / Koyyalamudi, Veerandra / Kraus, Molly B / Carey, Frederick J / Craner, Ryan

    Regional anesthesia and pain medicine

    2023  Volume 48, Issue 10, Page(s) 495–500

    Abstract: Background and objectives: Studies show variable spread with thoracic erector spinae plane (ESP) injections. Injection sites vary from lateral end of the transverse process (TP) to 3 cm from the spinous process, with many not describing the precise site ...

    Abstract Background and objectives: Studies show variable spread with thoracic erector spinae plane (ESP) injections. Injection sites vary from lateral end of the transverse process (TP) to 3 cm from the spinous process, with many not describing the precise site of injection. This human cadaveric study examined dye spread of ultrasound-guided thoracic ESP block at two needle locations.
    Methods: Ultrasound-guided ESP blocks were performed on unembalmed cadavers. Methylene blue (20 mL, 0.1%) was injected in the ESP at the medial TP at level T5 (medial transverse process injection (MED), n=7) and the lateral end of the TP between T4 and T5 (injection between transverse processes (BTWN), n=7). The back muscles were dissected, and the cephalocaudal and medial-lateral dye spread documented.
    Results: Dye spread cephalocaudally from C4-T12 in the MED group and C5-T11 in the BTWN group, and laterally to the iliocostalis muscle in five MED injections and all BTWN injections. One MED injection reached serratus anterior. Dorsal rami were dyed in five MED and all BTWN injections. Dye spread to the dorsal root ganglion and dorsal root in most injections, though more extensively in the BTWN group. The ventral root was dyed in 4 MED and 6 BTWN injections. Epidural spread in BTWN injections ranged from 3 to 12 levels (median: 5 levels), with contralateral spread in two cases and intrathecal spread in five injections. Epidural spread in MED injections was less extensive (median (range): 1 (0-3) levels); two MED injections did not enter the epidural space.
    Conclusion: An ESP injection administered between TPs exhibits more extensive spread than a medial TP injection in a human cadaveric model.
    MeSH term(s) Humans ; Thoracic Vertebrae/diagnostic imaging ; Nerve Block ; Ultrasonography ; Paraspinal Muscles/diagnostic imaging ; Cadaver ; Ultrasonography, Interventional
    Language English
    Publishing date 2023-02-16
    Publishing country England
    Document type Journal Article
    ZDB-ID 1425299-5
    ISSN 1532-8651 ; 1098-7339 ; 0146-521X
    ISSN (online) 1532-8651
    ISSN 1098-7339 ; 0146-521X
    DOI 10.1136/rapm-2022-104132
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  3. Article ; Online: Evaluating the Anatomic Spread of Selective Nerve Scalp Blocks Using Methylene Blue: A Cadaveric Analysis.

    Harbell, Monica W / Bolton, Patrick B / Koyyalamudi, Veerandra / Seamans, David P / Langley, Natalie R

    Journal of neurosurgical anesthesiology

    2021  Volume 35, Issue 2, Page(s) 248–252

    Abstract: Background: The modern scalp block consists of local anesthesia injections that target the supraorbital, supratrochlear, zygomaticotemporal, auriculotemporal, and greater and lesser occipital nerves. Limited data exist on the local anesthetic spread ... ...

    Abstract Background: The modern scalp block consists of local anesthesia injections that target the supraorbital, supratrochlear, zygomaticotemporal, auriculotemporal, and greater and lesser occipital nerves. Limited data exist on the local anesthetic spread that occurs with this technique. This study examines the extent of the spread of a scalp block using methylene blue in a cadaveric model.
    Methods: A traditional landmark-based scalp block was performed on 6 unembalmed human cadavers using 25-G, 1.5-inch needles to inject 1 to 2 mL of methylene blue 0.1% at each nerve bilaterally; a total volume of 20 mL was injected. The cadavers were then dissected, and the spread of injectate was measured and recorded.
    Results: All the nerves required for analgesic coverage were appropriately stained by the injections, except for in 2 specimens where the lesser occipital nerve could not be identified. The zygomatic (stained in 2 of 8 specimens) and temporal (stained in 5 of 8 specimens) branches of the facial nerve were stained as a result of the zygomaticotemporal and/or auriculotemporal injections. Tracking from the zygomatic injection site was noted as far inferior as the temporalis muscle attachments on the mandible.
    Conclusions: This cadaveric study confirms that the landmark-based technique for scalp blocks consistently stained all 6 nerves involved in scalp innervation. There was significant unintentional spread to the branches of the facial nerve when using the landmark technique.
    MeSH term(s) Humans ; Methylene Blue ; Scalp ; Nerve Block/methods ; Anesthetics, Local ; Cadaver
    Chemical Substances Methylene Blue (T42P99266K) ; Anesthetics, Local
    Language English
    Publishing date 2021-12-09
    Publishing country United States
    Document type Journal Article
    ZDB-ID 1018119-2
    ISSN 1537-1921 ; 0898-4921
    ISSN (online) 1537-1921
    ISSN 0898-4921
    DOI 10.1097/ANA.0000000000000826
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  4. Article ; Online: Lateral popliteal block in foot and ankle surgery: Comparing ultrasound guidance to nerve stimulation. A prospective randomized trial.

    Sagherian, Bernard H / Kile, Todd A / Seamans, David P / Misra, Lopa / Claridge, Richard J

    Foot and ankle surgery : official journal of the European Society of Foot and Ankle Surgeons

    2020  Volume 27, Issue 2, Page(s) 175–180

    Abstract: Background: The popliteal block has several benefits in foot and ankle surgery. It reduces postoperative pain, limits the use of narcotics and facilitates early discharge. The aim of this prospective randomized trial was to evaluate whether ultrasound ... ...

    Abstract Background: The popliteal block has several benefits in foot and ankle surgery. It reduces postoperative pain, limits the use of narcotics and facilitates early discharge. The aim of this prospective randomized trial was to evaluate whether ultrasound guidance improves block characteristics compared to the nerve stimulation technique in lateral popliteal blocks.
    Methods: Patients were randomized to receive either a lateral popliteal block using neurostimulation or ultrasound guidance. Block performance time, number of needle pricks, number of redirections were recorded. Pain upon admission to and discharge from post anesthesia care unit (PACU) was recorded. Block duration, patient satisfaction, pain at block site and amount of opioids used in PACU and between subsequent followup visits was recorded. Patients were followed for 12 weeks postoperatively.
    Results: There was no statistically significant difference between the two groups in terms of number of pricks, time for the block to wean, pain upon admission to PACU, amount of opioids received in PACU, pain upon discharge from PACU, pain at the operative site, pain at the block site, toe motor function and toe sensation. There was a statistically significant difference in the block procedure performance time between the two groups, with the control group being faster (P<0.0001). A significantly larger number of patients in the control group required more than three needle redirections (P=0.0060).
    Conclusions: The lateral sciatic popliteal block using nerve stimulation had similar block characteristics and patient satisfaction with a significantly faster performance time compared to the ultrasound guided technique.
    Level of evidence: Level I, prospective randomized study.
    MeSH term(s) Adult ; Aged ; Analgesics, Opioid/therapeutic use ; Ankle/innervation ; Ankle/surgery ; Electric Stimulation ; Female ; Foot/innervation ; Foot/surgery ; Humans ; Male ; Middle Aged ; Nerve Block/methods ; Pain Measurement ; Pain, Postoperative/prevention & control ; Prospective Studies ; Ultrasonography, Interventional
    Chemical Substances Analgesics, Opioid
    Language English
    Publishing date 2020-04-17
    Publishing country France
    Document type Journal Article ; Randomized Controlled Trial
    ZDB-ID 1424533-4
    ISSN 1460-9584 ; 1268-7731
    ISSN (online) 1460-9584
    ISSN 1268-7731
    DOI 10.1016/j.fas.2020.03.011
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  5. Article ; Online: Does Preoperative Pharmacogenomic Testing of Patients Undergoing TKA Improve Postoperative Pain? A Randomized Trial.

    Kraus, Molly B / Bingham, Joshua S / Kekic, Adrijana / Erickson, Colby / Grilli, Christopher B / Seamans, David P / Upjohn, David P / Hentz, Joseph G / Clarke, Henry D / Spangehl, Mark J

    Clinical orthopaedics and related research

    2023  Volume 482, Issue 2, Page(s) 291–300

    Abstract: Background: Pharmacogenomics is an emerging and affordable tool that may improve postoperative pain control. One challenge to successful pain control is the large interindividual variability among analgesics in their efficacy and adverse drug events. ... ...

    Abstract Background: Pharmacogenomics is an emerging and affordable tool that may improve postoperative pain control. One challenge to successful pain control is the large interindividual variability among analgesics in their efficacy and adverse drug events. Whether preoperative pharmacogenomic testing is worthwhile for patients undergoing TKA is unclear.
    Questions/purposes: (1) Are the results of preoperative pharmacogenetic testing associated with lower postoperative pain scores as measured by the Overall Benefit of Analgesic Score (OBAS)? (2) Do the results of preoperative pharmacogenomic testing lead to less total opioids given? (3) Do the results of preoperative pharmacogenomic testing lead to changes in opioid prescribing patterns?
    Methods: Participants of this randomized trial were enrolled from September 2018 through December 2021 if they were aged 18 to 80 years and were undergoing primary TKA under general anesthesia. Patients were excluded if they had chronic kidney disease, a history of chronic pain or narcotic use before surgery, or if they were undergoing robotic surgery. Preoperatively, patients completed pharmacogenomic testing (RightMed, OneOME) and a questionnaire and were randomly assigned to the experimental group or control group. Of 99 patients screened, 23 were excluded, one before randomization; 11 allocated patients in each group did not receive their allocated interventions for reasons such as surgery canceled, patients ultimately undergoing spinal anesthesia, and change in surgery plan. Another four patients in each group were excluded from the analysis because they were missing an OBAS report. This left 30 patients for analysis in the control group and 38 patients in the experimental group. The control and experimental groups were similar in age, gender, and race. Pharmacogenomic test results for patients in the experimental group were reviewed before surgery by a pharmacist, who recommended perioperative medications to the clinical team. A pharmacist also assessed for clinically relevant drug-gene interactions and recommended drug and dose selection according to guidelines from the Clinical Pharmacogenomics Implementation Consortium for each patient enrolled in the study. Patients were unaware of their pharmacogenomic results. Pharmacogenomic test results for patients in the control group were not reviewed before surgery; instead, standard perioperative medications were administered in adherence to our institutional care pathways. The OBAS (maximum 28 points) was the primary outcome measure, recorded 24 hours postoperatively. A two-sample t-test was used to compare the mean OBAS between groups. Secondary measures were the mean 24-hour pain score, total morphine milligram equivalent, and frequency of opioid use. Postoperatively, patients were assessed for pain with a VAS (range 0 to 10). Opioid use was recorded preoperatively, intraoperatively, in the postanesthesia care unit, and 24 hours after discharge from the postanesthesia care unit. Changes in perioperative opioid use based on pharmacogenomic testing were recorded, as were changes in prescription patterns for postoperative pain control. Preoperative characteristics were also compared between patients with and without various phenotypes ascertained from pharmacogenomic test results.
    Results: The mean OBAS did not differ between groups (mean ± SD 4.7 ± 3.7 in the control group versus 4.2 ± 2.8 in the experimental group, mean difference 0.5 [95% CI -1.1 to 2.1]; p = 0.55). Total opioids given did not differ between groups or at any single perioperative timepoint (preoperative, intraoperative, or postoperative). We found no difference in opioid prescribing pattern. After adjusting for multiple comparisons, no difference was observed between the treatment and control groups in tramadol use (41% versus 71%, proportion difference 0.29 [95% CI 0.05 to 0.53]; nominal p = 0.02; adjusted p > 0.99).
    Conclusion: Routine use of pharmacogenomic testing for patients undergoing TKA did not lead to better pain control or decreased opioid consumption. Future studies might focus on at-risk populations, such as patients with chronic pain or those undergoing complex, painful surgical procedures, to test whether pharmacogenomic results might be beneficial in certain circumstances.
    Level of evidence: Level I, therapeutic study.
    MeSH term(s) Female ; Humans ; Male ; Analgesics ; Analgesics, Opioid/therapeutic use ; Arthroplasty, Replacement, Knee/adverse effects ; Chronic Pain/diagnosis ; Chronic Pain/drug therapy ; Chronic Pain/genetics ; Pain, Postoperative/genetics ; Pain, Postoperative/prevention & control ; Pharmacogenomic Testing ; Practice Patterns, Physicians' ; Adolescent ; Young Adult ; Adult ; Middle Aged ; Aged ; Aged, 80 and over
    Chemical Substances Analgesics ; Analgesics, Opioid
    Language English
    Publishing date 2023-08-18
    Publishing country United States
    Document type Randomized Controlled Trial ; Journal Article
    ZDB-ID 80301-7
    ISSN 1528-1132 ; 0009-921X
    ISSN (online) 1528-1132
    ISSN 0009-921X
    DOI 10.1097/CORR.0000000000002767
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  6. Article ; Online: Using simulation and standardized patients to teach vital skills to pain medicine fellows.

    Hoelzer, Bryan C / Moeschler, Susan M / Seamans, David P

    Pain medicine (Malden, Mass.)

    2015  Volume 16, Issue 4, Page(s) 680–691

    Abstract: Introduction: Simulation is an evolving aspect of medical education. The role of simulation in training programs is variable, however, in technical specialties such as surgery and anesthesiology its role is quickly becoming a standard part of training ... ...

    Abstract Introduction: Simulation is an evolving aspect of medical education. The role of simulation in training programs is variable, however, in technical specialties such as surgery and anesthesiology its role is quickly becoming a standard part of training programs. Pain fellowship programs must teach clinical diagnostic skills, pharmacology and pathophysiology, in addition to interventional skills to fellows with varying residency backgrounds.
    Methods: The implementation of a hybrid simulation course into the pain fellowship curriculum allows for active learning as fellows experience challenging patient scenarios, stressful periprocedural events, and cases gone awry that require emergency algorithm recall and action.
    Conclusion: This report describes the incorporation of simulation and crucial conversations into a pain fellowship curriculum.
    MeSH term(s) Education, Medical, Graduate/methods ; Fellowships and Scholarships ; Humans ; Pain Management/methods
    Language English
    Publishing date 2015-04
    Publishing country England
    Document type Journal Article
    ZDB-ID 2015903-1
    ISSN 1526-4637 ; 1526-2375
    ISSN (online) 1526-4637
    ISSN 1526-2375
    DOI 10.1111/pme.12694
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  7. Article ; Online: Evaluating the extent of lumbar erector spinae plane block: an anatomical study.

    Harbell, Monica W / Seamans, David P / Koyyalamudi, Veerandra / Kraus, Molly B / Craner, Ryan C / Langley, Natalie R

    Regional anesthesia and pain medicine

    2020  Volume 45, Issue 8, Page(s) 640–644

    Abstract: Background and objectives: The erector spinae plane (ESP) block is a relatively new interfascial block technique. Previous cadaveric studies have shown extensive cephalocaudal spread with a single ESP injection at the thoracic level. However, little ... ...

    Abstract Background and objectives: The erector spinae plane (ESP) block is a relatively new interfascial block technique. Previous cadaveric studies have shown extensive cephalocaudal spread with a single ESP injection at the thoracic level. However, little data exist for lumbar ESP block. The objective of this study was to examine the anatomical spread of dye following an ultrasound-guided lumbar ESP block in a human cadaveric model.
    Methods: An ultrasound-guided ESP block was performed in unembalmed human cadavers using an in-plane approach with a curvilinear transducer oriented longitudinally. 20 mL of 0.166% methylene blue was injected into the plane between the distal end of the L4 transverse process and erector spinae muscle bilaterally in four specimens and unilaterally in one specimen (nine ESP blocks in total). The superficial and deep back muscles were dissected, and the extent of dye spread was documented in both cephalocaudal and medial-lateral directions.
    Results: There was cephalocaudal spread from L3 to L5 in all specimens with extension to L2 in four specimens. Medial-lateral spread was documented from the multifidus muscle to the lateral edge of the thoracolumbar fascia. There was extensive dye in and around the erector spinae musculature and spread to the dorsal rami in all specimens. There was no dye spread anteriorly into the dorsal root ganglion, ventral rami, or paravertebral space.
    Conclusions: A lumbar ESP injection has limited craniocaudal spread compared with injection in the thoracic region. It has consistent spread to dorsal rami, but no anterior spread to ventral rami or paravertebral space.
    MeSH term(s) Humans ; Nerve Block ; Paraspinal Muscles/diagnostic imaging ; Spinal Nerves ; Thoracic Vertebrae/diagnostic imaging ; Ultrasonography
    Language English
    Publishing date 2020-06-15
    Publishing country England
    Document type Journal Article
    ZDB-ID 1425299-5
    ISSN 1532-8651 ; 1098-7339 ; 0146-521X
    ISSN (online) 1532-8651
    ISSN 1098-7339 ; 0146-521X
    DOI 10.1136/rapm-2020-101523
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  8. Article ; Online: Evaluating the spread of costoclavicular brachial plexus block: an anatomical study.

    Koyyalamudi, Veerandra / Langley, Natalie R / Harbell, Monica W / Kraus, Molly B / Craner, Ryan C / Seamans, David P

    Regional anesthesia and pain medicine

    2020  Volume 46, Issue 1, Page(s) 31–34

    Abstract: Background and objectives: The costoclavicular brachial plexus block is performed deep and posterior to the midpoint of the clavicle. There are limited data evaluating the spread of the costoclavicular brachial plexus block. We performed a cadaveric ... ...

    Abstract Background and objectives: The costoclavicular brachial plexus block is performed deep and posterior to the midpoint of the clavicle. There are limited data evaluating the spread of the costoclavicular brachial plexus block. We performed a cadaveric study to evaluate the spread of injectate after a costoclavicular brachial plexus block.
    Methods: Five ultrasound-guided costoclavicular block injections were performed with 20 mL of 0.1% methylene blue. The brachial plexus and its branches were dissected from the level of C4 to the lower axilla. The extent of dye spread was recorded including spread to the phrenic nerve, suprascapular nerve, roots, trunks, divisions, cords and terminal branches of the brachial plexus.
    Results: The dye extended cephalad to the level of the cricoid cartilage in two of the five injections; three injections had dye extending 0.75 cm, 1.5 cm and 2 cm caudad to the level of the cricoid cartilage, respectively. The C7, C8 and T1 nerve roots were stained in all injections. The dye did not extend cephalad to the C5 and C6 nerve roots. All trunks, cords and divisions of the brachial plexus were stained, as was the suprascapular nerve. There was no spread of dye to the phrenic nerve in any of the specimens.
    Conclusions: This cadaveric study demonstrates that ultrasound-guided injection in the costoclavicular space spreads cephalad to the brachial plexus in the supraclavicular space, consistently reaching the suprascapular nerve and all trunks and cords of the brachial plexus, while sparing the phrenic nerve.
    MeSH term(s) Brachial Plexus/anatomy & histology ; Brachial Plexus/diagnostic imaging ; Brachial Plexus Block ; Cadaver ; Humans ; Phrenic Nerve/diagnostic imaging ; Ultrasonography, Interventional
    Language English
    Publishing date 2020-10-06
    Publishing country England
    Document type Journal Article
    ZDB-ID 1425299-5
    ISSN 1532-8651 ; 1098-7339 ; 0146-521X
    ISSN (online) 1532-8651
    ISSN 1098-7339 ; 0146-521X
    DOI 10.1136/rapm-2020-101585
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  9. Article ; Online: Fatal diffuse pulmonary fat microemboli following reperfusion in liver transplantation with the use of marginal steatotic allografts.

    Rosenfeld, David M / Smith, Maxwell L / Seamans, David P / Giorgakis, Emmanouil / Gaitan, Brantley D / Khurmi, Narjeet / Aqel, Bashar A / Reddy, Kunam S

    American journal of transplantation : official journal of the American Society of Transplantation and the American Society of Transplant Surgeons

    2019  Volume 19, Issue 9, Page(s) 2640–2645

    Abstract: Organ shortage is a major cause of delayed liver transplantation and increased waitlist time. The level of donor steatosis is a significant determinant in organ selection. Scarcity of organs has led some programs to expand their acceptable criteria for ... ...

    Abstract Organ shortage is a major cause of delayed liver transplantation and increased waitlist time. The level of donor steatosis is a significant determinant in organ selection. Scarcity of organs has led some programs to expand their acceptable criteria for the percentage of steatosis. We report two cases of liver transplantation of steatotic donor organs that resulted in mortality within hours from transplantation. Postmortem analysis showed evidence of diffuse pulmonary fat microemboli likely originating from the donor organ, with marked preservation reperfusion injury. The mechanism of diffuse fat microemboli in this setting and possible relationship to other perioperative syndromes (transfusion-related lung injury, acute kidney injury, and postreperfusion syndrome) is discussed.
    MeSH term(s) Allografts ; Biopsy ; Embolism, Fat/mortality ; Embolism, Fat/surgery ; Fatal Outcome ; Fatty Liver/mortality ; Fatty Liver/surgery ; Female ; Humans ; Liver/surgery ; Liver Diseases/mortality ; Liver Diseases/surgery ; Liver Transplantation/adverse effects ; Liver Transplantation/mortality ; Male ; Middle Aged ; Reperfusion ; Reperfusion Injury ; Tissue Donors ; Tissue and Organ Procurement
    Language English
    Publishing date 2019-05-21
    Publishing country United States
    Document type Case Reports ; Journal Article
    ZDB-ID 2060594-8
    ISSN 1600-6143 ; 1600-6135
    ISSN (online) 1600-6143
    ISSN 1600-6135
    DOI 10.1111/ajt.15399
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  10. Article ; Online: The Chitranjan Ranawat Award: Periarticular injections and femoral & sciatic blocks provide similar pain relief after TKA: a randomized clinical trial.

    Spangehl, Mark J / Clarke, Henry D / Hentz, Joseph G / Misra, Lopa / Blocher, Joshua L / Seamans, David P

    Clinical orthopaedics and related research

    2014  Volume 473, Issue 1, Page(s) 45–53

    Abstract: Background: Two of the more common methods of pain management after TKA are peripheral nerve blocks and intraarticular/periarticular injections. However, we are not aware of any study directly comparing the commonly used combination of a continuous ... ...

    Abstract Background: Two of the more common methods of pain management after TKA are peripheral nerve blocks and intraarticular/periarticular injections. However, we are not aware of any study directly comparing the commonly used combination of a continuous femoral block given with a single-shot sciatic block with that of a periarticular injection after TKA.
    Questions/purposes: This randomized clinical trial compared a combined femoral and sciatic nerve block with periarticular injection as part of a multimodal pain protocol after total knee arthroplasty with respect to (1) pain; (2) narcotic use; (3) quadriceps function and length of stay; and (4) peripheral nerve complications.
    Methods: One hundred sixty patients completed randomization into two treatment arms: (1) peripheral nerve blocks (PNB; n=79) with an indwelling femoral nerve catheter and a single shot sciatic block; or (2) periarticular injection (PAI; n=81) using ropivacaine, epinephrine, ketorolac, and morphine. All patients received standardized general anesthesia and oral medications. The primary outcome was postoperative pain, on a 0 to 10 scale, measured on the afternoon of postoperative day 1 (POD 1). Secondary outcomes were narcotic use, quadriceps function, length of stay, and peripheral nerve complications.
    Results: Mean pain scores on the afternoon of POD 1 were not different between groups (PNB group: 2.9 [SD 2.4]; PAI group: 3.0 [SD 2.2]; 95% confidence interval, -0.8 to 0.6; p=0.76). Mean pain scores taken at three times points on POD 1 were also similar between groups. Hospital length of stay was shorter for the PAI group (2.44 days [SD 0.65] versus 2.84 days [SD 1.34] for the PNB group; p=0.02). Narcotic consumption was higher the day of surgery for the PAI group (PAI group: 11.7 mg morphine equivalents [SD 13.1]; PNB group: 4.6 mg [SD 9.1]; p<0.001), but thereafter, there was no difference. More patients in the PNB group had sequelae of peripheral nerve injury (mainly dysesthesia) at 6-week followup (nine [12%] versus one [1%]; p=0.009).
    Conclusions: Patients receiving periarticular injections had similar pain scores, shorter lengths of stay, less likelihood of peripheral nerve dysesthesia, but greater narcotic use on the day of surgery compared with patients receiving peripheral nerve blocks. Periarticular injections provide adequate pain relief, are simple to use, and avoid the potential complications associated with nerve blocks.
    Level of evidence: Level I, therapeutic study. See Guidelines for Authors for a complete description of levels of evidence.
    MeSH term(s) Adrenergic Agonists/administration & dosage ; Aged ; Analgesics/administration & dosage ; Analgesics/adverse effects ; Analgesics, Opioid/administration & dosage ; Anesthetics, Local/administration & dosage ; Anti-Inflammatory Agents, Non-Steroidal/administration & dosage ; Arthroplasty, Replacement, Knee/adverse effects ; Awards and Prizes ; Female ; Femoral Nerve ; Humans ; Injections, Intra-Articular ; Knee Joint/physiopathology ; Knee Joint/surgery ; Length of Stay ; Male ; Middle Aged ; Minnesota ; Nerve Block/adverse effects ; Nerve Block/methods ; Pain Measurement ; Pain, Postoperative/diagnosis ; Pain, Postoperative/etiology ; Pain, Postoperative/prevention & control ; Peripheral Nervous System Diseases/etiology ; Quadriceps Muscle/physiopathology ; Quadriceps Muscle/surgery ; Recovery of Function ; Sciatic Nerve ; Time Factors ; Treatment Outcome
    Chemical Substances Adrenergic Agonists ; Analgesics ; Analgesics, Opioid ; Anesthetics, Local ; Anti-Inflammatory Agents, Non-Steroidal
    Language English
    Publishing date 2014-04-05
    Publishing country United States
    Document type Comparative Study ; Journal Article ; Randomized Controlled Trial
    ZDB-ID 80301-7
    ISSN 1528-1132 ; 0009-921X
    ISSN (online) 1528-1132
    ISSN 0009-921X
    DOI 10.1007/s11999-014-3603-0
    Database MEDical Literature Analysis and Retrieval System OnLINE

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