Marco Nadig

Double Epidural Catheter with Ropivacaine versus Intravenous Morphine: A Comparison for Postoperative Analgesia after Scoliosis Correction Surgery

Background: Major spine surgery with a dorsal or ventrodorsal approach causes severe postoperative pain. The use of continuous epidural analgesia through one or two epidural catheters placed intraoperatively by the surgeon has been shown to provide efficient postoperative pain control. In this prospective unblinded study, the authors compared the efficacy of continuous intravenous morphine with a continuous double epidural catheter technique with ropivacaine after scoliosis correction. Methods: Thirty patients with American Society of Anesthesiology physical status I-III were prospectively randomized to either the morphine group or the epidural group. At the end of surgery, patients in the epidural group received two epidural catheters placed by the surgeon, one directed cephalad and one caudally. Correct placement was checked radiographically. Postoperative analgesia until the first postoperative morning was performed with remifentanil target-control infusion for all patients. From that time remifentanil was stopped and continuous intravenous analgesia with morphine or double epidural analgesia with ropivacaine 0.3% was initiated (T o = beginning of study). Pain at rest and pain in motion (using a visual analog scale from 0-100), the amount of rescue analgesics, sensory level, motor blockade, postoperative nausea and vomiting, and pruritus were assessed every 6 h and bowel function was assessed every 12 h until T 72 (end of study). Two days later, patient satisfaction was assessed. Results: Pain scores at rest were significantly decreased in the epidural group at all time points except at T 12 , T 60 , and T 72 . Pain scores in motion were significantly decreased in the epidural group at T 24 , T 40 , and T 72 . Bowel activity was significantly better in the epidural group at T 24 , T 36 , T 48 , and T 60 . Postoperative nausea and vomiting and pruritus occurred significantly less frequently in the epidural group. No complications related to the epidural catheter occurred. Conclusions: Both methods provide efficient postoperative analgesia. However, double epidural catheter technique provides better postoperative analgesia, earlier recovery of bowel function, fewer side effects, and a higher patient satisfaction.

Postoperative analgesia after anterior correction of thoracic scoliosis: a prospective randomized study comparing continuous double epidural catheter technique with intravenous morphine.

Study Design. Prospective randomized comparative study of two techniques for postoperative analgesia. Objective. Assess the efficacy of two epidural catheters compared with intravenous morphine after anterior correction of thoracic scoliosis. Summary of Background Data. Spine surgery with anterior thoracotomy can cause severe postoperative pain. Continuous epidural analgesia through two epidural catheters was shown to be effective after posterior scoliosis correction. The efficacy of this technique has still not been demonstrated in this surgical context. Methods. Thirty adolescent patients with thoracic idiopathic scoliosis scheduled for anterior correction were prospectively randomized into morphine (M) or epidural (E) group. In the E group, two epidural catheters were placed transforaminally after scoliosis correction. The immediate postoperative analgesia was performed with remifentanil in all patients until the first postoperative morning (T0 = begin of study), when either continuous intravenous morphine (M group) or continuous epidural ropivacaine 0.3% (E group) was initiated. Pain at rest and in motion, morphine consumption, sensory level, motor blockade, nausea/vomiting, pruritus, bowel function, and patient satisfaction were assessed. Results. In the E group, there was significantly less pain at rest and in motion, less rescue morphine consumption, improved bowel activity, and higher patient satisfaction. The incidence of side effects was significantly higher in M group. Conclusions. Two epidural catheters provide better postoperative analgesia with fewer side effects and higher patient satisfaction after anterior instrumentation of thoracic scoliosis.

Continuous brachial plexus block at the cervical level using a posterior approach in the management of neuropathic cancer pain

Background and Objectives Neuropathic cancer pain due to tumor growth near the brachial plexus is often treated with a combination of nonsteroidal anti-inflammatory drugs, tricyclic antidepressants, anticonvulsants, and oral or transdermal opioids. We propose placement of a catheter along the brachial plexus using a posterior approach for patients not responding to the above-mentioned treatment. Case Report We describe 2 patients with neuropathic cancer pain in the arm and shoulder despite treatment with dexamethasone, amitriptyline, gabapentin, opioids, and, in 1 patient, oral ketamine. An increase in daily opioid dosage did not relieve the pain but caused unacceptable side effects of nausea, vomiting, and sedation. Continuous administration of local anesthetics via a brachial plexus catheter inserted at the cervical level using a posterior approach resulted in a markedly improved analgesia and decreased opioid requirement. Conclusion Continuous brachial plexus block should be considered in patients with severe neuropathic cancer pain in the arm and shoulder. To achieve sufficient pain relief for prolonged periods of time, a catheter was inserted to block the brachial plexus using a posterior approach. This technique may be a valuable alternative to the interscalene approach because of the improved fixation of the catheter in the muscle sheet of the trapezius, splenius cervicus, and levator scapulae muscles, and the decreased likelihood of catheter dislodgment during neck movements.

Paravertebral approach to the brachial plexus: an anatomic improvement in technique--is it really advantageous to come from behind?

1. Borgeat A, Tewes E, Biasca N, Gerber C. Patient-controlled interscalene analgesia with ropivacaine after major shoulder surgery: PCIA vs PCA. Br J Anaesth 1998;81:603-605. 2. Borgeat A, Schappi B, Biasca N, Gerber C. Patient-controlled analgesia after major shoulder surgery: Patient-controlled interscalene analgesia versus patient-controlled analgesia. Anesthesiology 1997;87:1343-1347. 3. Klein SM, Grant SA, Greengrass RA, Nielsen KC, Speer KP, White W, Warner DS, Steele SM. Interscalene brachial plexus block with a continuous catheter insertion system and a disposable infusion pump. Anesth Analg 2000;91:1473-1478. 4. Ilfeld BM, Morey TE, Wright TW, Chidgey LK, Enneking FK. Continuous interscalene brachial plexus block for postoperative pain control at home: A randomized, double-blinded, placebo-controlled study. Anesth Analg 2003;96:1089-1095. 5. Klein SM, Steele SM, Nielsen KC, Pietrobon R, Warner DS, Martin A, Greengrass RA. The difficulties of ambulatory interscalene and intra-articular infusions for rotator cuff surgery: a preliminary report. Can J Anaesth 2003;50:265-269. 6. Grant SA, Nielsen KC, Greengrass RA, Steele SM, Klein SM. Continuous peripheral nerve block for ambulatory surgery. Reg Anesth Pain Med 2001;26:209-214. 7. Coleman MM, Chan VW. Continuous interscalene brachial plexus block. Can J Anaesth 1999;46:209-214. 8. Boezaart AP, Koorn R, Rosenquist RW. Paravertebral approach to the brachial plexus: An anatomic improvement in technique. Reg Anesth Pain Med 2003;28:241-244. 9. Borgeat A, Ekatodramis G, Kalberer F, Benz C. Acute and nonacute complications associated with interscalene block and shoulder surgery: A prospective study. Anesthesiology 2001;95:875-880.

Combined infraclavicular plexus block with suprascapular nerve block for humeral head surgery in a patient with respiratory failure: is an alternative approach really the best option for the lungs?

To the Editor:—We read with interest the recent report by Martinez et al. regarding a combined infraclavicular plexus blockade with suprascapular nerve block for humeral head surgery in a patient with severe respiratory failure. However, we have some concerns with regard to the following points: First, it is not clearly stated whether the authors performed an infraclavicular plexus block using the coracoid technique (originally described by Whiffler) or the vertical infraclavicular technique (described by Kilka et al.). In the case report section the authors wrote, “brachial plexus was performed using “the coracoid and infraclavicular technique.” However, figure 1B in the case report of Martinez et al. shows the territories usually blocked by the vertical infraclavicular brachial plexus block. One must be aware of the different extensions of sensory blockade produced by the coracoid technique, the vertical infraclavicular technique, and the modified approach of the Raj technique. Because the coracoid technique approaches the brachial plexus more distally than the vertical infraclavicular technique, the axillary and musculocutaneus nerves are often missed or are not adequately blocked with the former technique. Deleuze et al. described a successful sensory blockade of the axillary nerve by the coracoid technique in only about 22%. Gaertner et al. showed that a multiple injection technique, as compared to a single injection, improved the overall success rate of the coracoid technique from 40% up to more than 70%, without detailing the effect on the axillary nerve. Martinez performed a suprascapular nerve block to avoid hemidiaphragmatic paresis secondary to interscalene brachial plexus block. In the current case, the possibility of an iatrogenic pneumothorax during this procedure must be mentioned. This theoretical disadvantage is also described for the vertical infraclavicular technique. In the current case, a pneumothorax could have been at least as deleterious as a phrenic nerve paresis. As shown by Borgeat et al. and Boezaart et al., the decrease of hemidiaphragmatic excursion after interscalene brachial plexus block can be reduced when the block is performed through the interscalene catheter rather than with a single bolus. The catheter technique, either performed at the interscalene or at the infraclavicular level (where the modified approach of the Raj technique seems to be the optimal solution), would have also offered good surgical conditions and efficient postoperative analgesia without the danger of a pneumothorax or an insufficient block.

What to do with clonidine with long-acting local anesthetic in brachial plexus block?

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