includes newer blocks,new drugs and techniques for regional anesthesia

1. NEW AND EMERGING
CONCEPTS IN NERVE
BLOCKS
PRESENTER-DR. ANAMIKA
YADAV

2. TOPICS TO COVER
1.NEW EQUIPMENTS-
A.ECHOGENIC NEEDLES,ECHOGENIC CATHETERS AND SENSe
B.ULTRASONIC DEVICES-3D,4D,GPS AND CORDLESS USG DEVICES
C.PRESSURE MONITORING DEVICES
2.LEARNING TOOLS-
A.PHANTOMS
B.ROBOTS
3.PHARMACOLOGY-
A.LIPOSOMAL BUPIVACAINE
B.PROLIPOSOMAL ROPIVACAINE
C.ADJUVANTS TO PROLONG PERIPHERAL NERVE BLOCKS

3. TOPICS TO COVER
4.NEWER NERVE BLOCKS-
A.ERECTOR SPINAE BLOCK
B.RHOMBOIDES BLOCK
C.SHAMROCK BLOCK
D.ARTICULATING BRACH OF FEMORAL NERVE BLOCK
E.TRANSVERSALIS FASCIA PLANE BLOCK
F.COSTOCLAVICULAR BLOCK
5.LIA-LOCAL INFILTRATION ANALGESIA
6.SOME NEW TECHNIQUES IN PAIN MEDICINE
POSTAMPUTATION PAIN T/T
FREEZING SENSORY NERVE BLOCK PRIOR TO KNEE SX /CRYOANALGESIA

4. ECHOGENIC NEEDLES AND
CATHETERS
ECHOGENIC NEEDLES ARE MADE SO AS TO INCREASE THE REFLECTION OF
ULTRASONIC WAVES BACK TO THE TRANSDUCER
THIS IS ACHIEVED BY INCREASING THE VISUAL CONTRAST BETWEEN THE
NEEDLE AND THE SURROUNDING TISSUE BY- COATING THE NEEDLE WITH
TEFLON OR POLYMER ,TEXTURING,DIMPLING,ROUGHENING ETC
THESE NEEDLES PRODUCE FEWER ARTIFACTS AND HAVE A REDUCED IMPACT
ON THE NEEDLE HANDLING AND FEEL.
 Limited data exist regarding the echogenicity of perineural catheters, but
visualization is crucial to ensure accurate placement and efficacy of the
subsequent local anesthetic infusion.

6. SOME EXAMPLES OF ECHOGENIC
NEEDLES

8. ECHOGENIC CATHETERS
Includes: 20 Ga. x 55 cm Contiplex Echo Open-tip Catheter with
Stylet and Threading Assist Guide, Contiplex Tuohy Ultra Needle,
Sideport Valve, and Catheter Connector

9. SENSE(SEQUENTIAL ELECTRICAL
NERVE STIMULATION)
 Alternating sequential electrical pulses(3) of differing pulse durations at a set frequency of 3 Hz
 High pulse durations increase sensitivity
 The third impulse has longer reach into the tissue.
 Muscle twitches at 3Hz per second indicate needle is positioned closer to the nerve
 The impulse duration of the third impulse decreases with stimulus amplitude below 2.5 mA

11. SENSE…ADVANTAGES
 Clinically, there is more motor response information at distance from the nerve. Moving
the needle toward the nerve increases the strength or frequency of the motor response.
 Continuous feedback and markedly diminishes the disappearance of motor responses
once they are encountered
 Increases visual clues and feedback
 Less necessity to adjust the amperage control of the nerve stimulator.

12. ULTRASONOGRAPHY ADVANCES
1.3D USG
2.4D USG
3.GPS IN USG
4.HANDHELD USG( iPhone iPad laptop)
5.WIRELESS PROBES

13. USG…
3D-Mechanical/matrix probe
Mechanically swept transducer inside a standard probe that moves
through a known trajectory –obtains 2D scans that are converted to
3D images
Matrix array transducer utilizes more than 2400 peizo electric
elements –acquire a direct 3D image
4D-Simultaneous visualisation of multiple planes of view
Spatial relationship between anatomical structures of interest
Measuring local anesthetic spread and tracking fluid dissipation in
fascial compartments
GPS USG-Electromagnetic sensors are mounted on both the
transducer and needle tip
These sensors enable the device to determine actual needle tip
position in relation to the transducer

14. USG ADVANCES..ADVANTAGES
3D-PROVIDES MORE DETAILED ANATOMICAL INFORMATION AND
BETTER SPATIAL ORIENTATION THAN 2D IMAGE.
4D-IT ENHANCES THE VISUALISATION OF A PARTICULAR ANATOMY
AND OFFERS REAL TIME ASSESSMENT OF LOCAL ANESTHETIC SPREAD
DURING USG RA TECHNIQUES.(BASICALLY A LIVE 3D WHERE TIME IS
THE FOURTH DIMENSION)
GPS IN USG-ELECTROMAGNETIC TRACKING CAN FACILITATE NEEDLE
BEAM ADJUSTMENTS FOR IN PLANE APPROACH AND INDICATES WHERE
THE NEEDLE CROSSES THE BEAM DURING OUT OF PLANE USG
TECHNIQUE.
HANDHELD USG AND CORDLESS PROBE ALLOWS EASY USE AND EASY
AVAILABILITY AND PORTABILITY ,CAN BE USED DURING EMERGENCY
LIKE TRAUMA CASES FOR AIRWAY ANATOMY,IN CASES OF EMERGENCY
TRACHEOSTOMY OR CASES WITH DISTORTED AIRWAY
ANATOMY.(MATRIX TRANSDUCERS ARE LIGHTER)

26. PRESSURE MONITORING DEVICES
These are disposable manometer to monitor injection pressure during
performance of peripheral nerve blocks.
It provides visual indication of injection pressure.
The syringe feel method for assessing the injection force is inconsistent and
thus this provides objective method of monitoring and documenting
injection pressure irrespective of who performs it.
One such example is B-Smart injection pressure monitor.
Intrafascicular injections->15 Psi-associated with severe fascicular injury
and persistent neurological deficits
97% detection of needle nerve contact
(>=15 Psi),intraneural inflammatory changes
Perineural injections typically <4 Psi
Thus is a preventable complication.

27. HOW TO USE IT?
Priming the B-Smart Pressure Monitor 1. Attach the B-Smart monitor to filled syringe
2. Attach needle tubing to the B-Smart monitor 3. Flush system, ensuring the B-
Smart monitor’s piston rises so “> 20 psi” (orange) is visible. The B-Smart monitor’s
piston must move upward during priming in order for the device to be ready to use.
It may be helpful to obstruct the injection tubing to accomplish this.
-
2
0
p
s
i
-
2
0
p
s
i
-
2
0
p
s
i

28. LEARNING TOOLS-PHANTOMS
 Calibration and testing of diagnostic ultrasound machines requires accurate
representation and sonographic characteristics of human tissue.
 The physical properties, including speed of sound and attenuation, are tailored to
be the same as those of human tissue
 TYPES OF PHANTOMS-
• Water
• Agar
• Gelatin
 Elastomeric rubber-BLUE PHANTOMS (BETTER TACTILE FEEDBACK,NO
REFRIGERATION REQD. AND LESS NEEDLE TRACK ARTIFACTS,REUSABLE MULTIPLE
TIMES BUT EXPENSIVE AND DIFFICULT TO PREPARE)
 Other option-
• Meat and Cadavers.

29. PHANTOMS-
PROPERTIES OF A GOOD PHANTOM-ECHOGENECITY OF HUMAN
TISSUE,READILY AVAILABLE,INEXPENSIVE,REUSABLE,GIVES TACTILE
FEEDBACK,HOLDS NEEDLE IN PLACE AND DOESN’T GENERATE NEEDLE
TRACKS AND NO EXPOSURE TO HEALTH HAZARDS.
Water phantoms- development and investigation of new UGRA techniques
 Non-meat- practising needle placement
 Meat based-realistic tissue feedback,local anaesthetic injection
 Cadaver based-realistic environment

33. Sample sonogram of a nonanatomic inorganic phantom for
ultrasound-guided regional anesthesia.
Sample sonogram of an organic phantom for ultrasound-guided
regional anesthesia using a porcine meat specimen with inserted
bovine tendon to represent the target “nerve” (arrowheads
identify the tendon).

34. LEARNING TOOLS-ROBOTS
MAGELLAN ROBOTIC NERVE BLOCK SYSTEM
PARTS-
1.Thrustmaster-joystick with two handles
2. JACO-Robotic arm
3. Software control system
4. Graphical user interface

39. ADVANCES IN PHARMACOLOGY
A.LIPOSOMAL BUPIVACAINE (EXPAREL-Brand name)
 Liposomes are microscopic structures consisting of a phospholipid bilayer
encapsulating an aqueous core
 UNILAMELLAR-single lipid bilayer surrounding the aqueous core
 MULTILAMELLAR-concentric lipid bilayers
 MULTIVESICULAR-nonconcentric lipid bilayers

40. LIPOSOMAL BUPIVACAINE
LIPOSOMAL BUPI IS FORMULATED TO DELIVER BUPI SLOWLY OVER
TIME TO EXTEND ITS DURATION OF ACTION.
DEPOFOAM IS A PRESERVATIVE FREE AQUEOUS SOLUTION OF
MULTIVESICULAR LIPOSOMES CONTAINING BUPI AT A
CONCENTRATION OF 13.3 MG/ML(EXPRESSED AS AN ANHYDROUS
BUPI HCL EQUIVALENT )AND PLUS 3 % FREE BUPIVACAINE.
THIS FORMULATION PRODUCES TWO PEAKS ONE AFTER FREE
BUPIVACAINE ACTS (FIRST ORDER RELEASE) AND OTHER AFTER
GRADUAL RELEASE OF BUPIVACAINE (SECOND ORDER RELEASE).
TMAX (TIME TO PEAK PLASMA CONC.) IS 12 HR FOR LIPOSOMAL BUPI
V/S 0.6 HR FOR BUPI HCL.

41. PEG LIPOSOMES...
BIOFUNCTIONALIZING THE LIPOSOMES WITH POLYETHYLENE
GLYCOL(PEG),PREVENTS THE INTERACTION BETWEEN THE LIPOSOMAL
NANOVESICLES AND THE MONONUCLEAR PHAGOCYTIC SYSTEM AND
OBTAINS A HIGHER PHARMACOKINETIC RESPONSE.

42. PROLIPOSOMAL ROPIVACAINE
NEW PRODUCT DEVELOPED AND TESTED BY DR. YEHUDA GINOSAUR
OF HEBREW UNIVERSITY,JERUSALEM.FIRST TESTED IN PIGS WHERE
SINGLE DOSE STAYED FOR 4 DAYS THEN IN HUMANS.
IN HUMANS AFTER INJECTION ANESTHESIA TO PINPRICK LASTED ON
AN AVG OF 29 HRS V/S 16 HRS IN PLAIN ROPIVACAINE.
FOR HEAT AND PAIN SENSATION IT LASTED FOR 36 HRS V/S 12 HRS
FOR PLAIN BUPIVACAINE.
BUT IN THIS TEST 4 % ROPIVACAINE FORMULATION WAS USED,
ALMOST 8 TIMES THE DOSE NORMALLY USED.

43. PROLIPOSOMAL ROPIVACAINE
ADVANTAGES OVER OTHER LIPOSOMAL AND PLAIN PREPARATIONS-
IT DOESNOT BECOME LIPOSOMAL UNTIL INJECTED AND CAME IN
CONTACT WITH AQUEOUS SOLUTION I.E, PLASMA AND HENCE THE
NAME PROLIPOSOMAL.
CURRENT LIPOSOMAL PPTNS HAVE A SHELF LIFE OF 1-2 MONTHS AND
PROLIPOSOMAL ROPIVACAINE OIL HAS A SHELF LIFE OF 2 YEARS EVEN
AT ROOM TEMPERATURE.
IT IS ALSO EASY TO PREPARE.
IT COULD SIGNIFICANTLY EXTEND DURATION OF PAIN CONTROL
AFTER INFILTRATION OF LOCAL ANESTHETICS-A WORTHY BUT SO FAR
ELUSIVE GOAL.

44. Liposome-encapsulated ropivacaine for topical anesthesia of human oral mucosa.
Franz-Montan M1, Silva AL, Cogo K, Bergamaschi Cde C, Volpato MC, Ranali J, de Paula
E, Groppo FC.
Adductor Canal Block With Bupivacaine Liposome Versus Ropivacaine Pain Ball for Pain Control in
Total Knee Arthroplasty: A Retrospective Cohort Study.
Wang Y1, Klein MS2, Mathis S2, Fahim G3.
Liposomal bupivacaine demonstrated statistically
significant impact in pain control in the first 36
hours, but by the end of the 72-hour interval, it was
comparable to RPB in postoperative pain
management. Using bupivacaine liposome did
provide direct and total cost savings compared with
RPB.

45. ADJUVANTS TO PROLONG
PERIPHERAL NERVE BLOCKSMany studies have been done on adjuvants to local anesthetics to prolong action
of nerve blocks.
Various adjuvants studies are many as follows-
1.DEXAMETHASONE
2.CLONIDINE
3.DEXMETEDOMIDINE
4.SODIUM BICARBONATE
5.EPINEPHRINE
6.MAGNESIUM
7.MIDAZOLAM
8.TRAMADOL
9.BUPRENORPHINE
10.KETAMINE

46. ADJUVANTS…
DEXAMETHASONE-10 mg dose prolongs action by 10 hrs acc to one
study but no definitive and detailed study available,maximum clinical
trials have found it to be not so effective.
CLONIDINE-150 mcg dose prolonged analgesia in one study by 2
hrs,one more study showed shorter motor blockade duration when
added to ropivacaine than with bupivacaine, but found to have
neurotoxic effects according to another study.
SODIUM BICARBONATE-found to have shorter onset time in a study
but overall in others no significant increase in duration of action
,neurotoxicity profile unknown.
EPINEPHRINE-prolongs duration of action of LA but decreases blood
supply to neural tissue,still recommended as IV injection marker in
dose of 2.5mcg/ml ,if giving in block in ways other than USG

47. ADJUVANTS
MAGNESIUM-prolongs duration of action but further studies required for its
efficacy and neurotoxicity profile.
MIDAZOLAM -not recommended infact found to be neurotoxic.
KETAMINE- not recommended infact found to be neurotoxic.
BUPRENORPHINE-prolongs analgesic action by 12 hrs but side effects nausea
vomiting are distressing,also not studied in detail.
TRAMADOL-in dose of 1.5 mg/kg has not been found to be very efficacious.

48. DEXMEDETOMIDINE
Study by Kettner et al in Austria shows a significant increases in duration of
action when added in peripheral nerve blocks .
It acts by blocking the hyperpolarization activated cation current in the
peripheral nerves,renders them refractory to stimulation.
Fristch et al found 150 mcg hastened sensory and motor block and
prolongation by 240 min with no hemodyanamic instability.
Marhofer et al found as low as 20 mcg prolonged ulnar nerve sensory block
by 248 min and motor block by 205 min.
Sandhya Agarwal et al found 100 mcg shortens the onset time and
prolonged the duration of action significantly when mixed with 0.325 %
bupivacaine ,755 min sensory v/s 234 min and 702 min for motor block v/s
208 min.
Surprisingly,both motor and sensory block prolongation found with iv
administration of dexmed 20 mcg by 45 and 90 min respectively.(FDA
approved)
It appears to be a promising upcoming drug for peripheral nerve blocks.

49. NEW NERVE BLOCKS…

50. ERECTOR SPINAE BLOCK
ERECTOR SPINAE MUSCLE ORIGINATES FROM SPINOUS PROCESS OF T9
TO T12 THORACIC VERTEBRAE AS WELL AS THE MEDIAL SLOPE OF THE
DORSAL SEGMENT OF THE ILIAC CREST.
IT GETS INSERTED TO THE SPINOUS PROCESS OF T1 AND T2
THORACIC VERTEBRAE AND THE CERVICAL VERTEBRAE AS WELL.
IT IS A GROUP OF MUSCLES ,ILIOCOSTALIS LATERALLY,LONGISSIMUS
INTERMEDIATE AND SPINALIS MEDIALLY.
IT RUNS THROUGHOUT LUMBAR,THORACIC AND CERVICAL REGION IN
GROOVE TO THE SIDE OF THE VERTEBRAL COLUMN.

54. ERECTOR SPINAE BLOCK
DESCRIBED BY MAURICIO FORERO ET AL
IT’S A MULTIDERMATOMAL SENSORY BLOCK T2-T9
ACTS ON DORSAL AND VENTRAL RAMI OF THORACIC SPINAL NERVES
BENEFITIAL FOR NEUROPATHIC PAIN LIKE METASTASIS TO RIBS OR MALUNION
AFTER MULTIPLE RIB FRACTURES,POSTSURGICAL AND POST TRAUMATIC
PAIN.
PROVIDES PAIN RELIEF UPTO 36 HOURS.

55. ERECTOR SPINAE BLOCK
TECHNIQUE-PROBE IS PLACED IN LONGITUDINAL ORIENTATION OVER TIP OF
T5 TRANSVERSE PROCESS AND BOCK NEEDLE IS ADVANCED CEPHALAD TO
CAUDAD DIRECTION TO CONTACT THE TRANSVERSE PROCESS THEN
WITHDRAWN TO GIVE DRUG.
DRUG CAN BE DEPOSITED EITHER ABOVE ERECTOR SPINAE(TYPE 1,LESS
EFFICACIOUS)
OR CAN BE DEPOSITED BELOW ERECTOR SPINAE AND TRANSVERSE
PROCESSES(TYPE 2,MORE LINEAR SPREAD WITH BETTER RESULTS)
AREA COVERED-T2-T9 ,3CM LATERAL TO THE THORACIC SPINE TO
MIDCLAVICULAR LINE,ALSO AXILLA AND MEDIAL UPPER PART OF ARM GETS
THE SENSORY BLOCKADE
DRUG -0.25 % BUPIVACAINE 20 ML
6-13 MHZ LINEAR USG PROBE IN SITTING POSITION.

58. T4
T5
ES
RHOIMBOID
ES
TRAPEZIUS

59. NEEDLE INSERTED
TO T5 AND THEN
WITHDRAWN
T5
LA
SPREAD

60. ADVANTAGES OF ERECTOR SPINAE
BLOCK
EASY SONOANATOMY
SAFER AND SIMPLE BLOCK V/S INTERCOSTAL AND PARAVERTEBRAL WHICH ARE
MORE INVASIVE THUS CAN BE USED AS AN OPD BLOCK.
PECTORAL AND SERRATUS ANTERIOR BLOCK DOESNOT COVER THE VAST
SENSORY BLOCK AREA V/S ERECTOR SPINAE BLOCK AS IT COVERS AXILLA AND
ANTEROLATERAL CHEST WALL AREA AS WELL.
CATHETER CAN BE PUT FOR LONG TERM USE AS WELL.
MORE STUDIES ARE REQUIRED TO CHECK ITS EFFICACY.

61. RHOMBOIDES BLOCK
DESCRIBED BY H.ELSHARKAWY ET AL.
PECTORAL AND SERRATUS PLANE BLOCK DON’T COVER THE POSTERIOR PRIMARY
RAMI WHICH CAN BE ACHIEVED BY INFILTRATION OF LOCAL ANESTHETICS INTO
INTERFASCIAL PLANE ON POSTERIOR CHEST WALL IN TRIANGLE OF
AUSCULTATION (TOA)KNOWN AS RHOMBOIDES BLOCK.
TOA IS LOCATED ALONG LOWER MEDIAL BORDER OF SCAPULA
BOUNDARIES-
SUPERIORLY-TRAPEZIUS
INFERIORLY-LATISSIMUS DORSI
LATERALLY-VERTEBRAL BORDER OF SCAPULA
FLOOR IS FORMED BY LOWER PART OF RHOMBOID MAJOR,LATERAL PART OF
ERECTOR SPINAE AND SERRATUS ANTERIOR MUSCLES OVERLYING 6TH TO 7TH RIBS
AND THEIR INTERNAL AND EXTERNAL INTERCOSTAL MUSCLES.

62. RHOMBOIDES BLOCK
TISSUE PLANE BETWEEN FLOOR OF TOA (RHOMBOIDES MAJOR) AND THE
INTERCOSTALS EXTENDS MEDIALLY BELOW ERECTOR SPINAE,LATERALLY
CROSSES MIDAXILLARY LINE BELOW SERRATUS ANTERIOR.
PATIENT POSITION-PRONE AND ARMS ADDUCTED ACROSS THE CHEST TO
PUSH THE SCAPULA LATERALLY.
LINEAR USG PROBE (6-13 MHZ) PLACED MEDIAL TO THE LOWER BORDER OF
SCAPULA WITH THE MARKER DIRECTED CRANIALLY.
PLANE IS IDENTIFIED ,SINGLE INJECTION GIVEN AT T6-T7 LEVEL
25 ML OF 0.25 % BUPIVACAINE
AREAS COVERED-T2-T9 ,ANTERIOR HEMITHORAX JUST MEDIAL TO THE
MIDLINE ,LATERAL FROM AXILLA TO T9 AND POSTERIOR HEMITHORAX UPTO
MEDIAL OF THE MIDLINE.THUS COVERS MORE AREA V/S ERECTOR SPINAE.
FURTHER MORE STUDIES ARE REQUIRED LOOKS PROMISING.

65. ARTICULATING BRANCH OF
FEMORAL NERVE (ABFN)BLOCK
It is a new block ,few studies done and shown to have a good post
operative pain relief profile in patients undergoing Hip Arthroplasty
(as necessity of good pain relief as well as mobilisation)
This block involves very less side effects.
Anatomy of ABFN-
ANTERIORLY-SARTORIUS
LATERALLY-RECTUS FEMORIS
MEDIALLY-ILIACUS

66. ABFN …
Typically Obturator nerve block was used to relieve hip pain uptil now
but found to have a lot of sparing.
This led to some anatomical studies eg K.Birhaum et al who
concluded following-
HIP JOINT CAPSULE SUPPLY-
ANTEROMEDIAL-ARTICULAR BR OF OBTURATOR NERVE
ANTERIOR-SENSORY ARTICULAR BR OF FEMORAL NERVE(ABFN)
POSTERIOR-ARTICULAR BR OF SCIATIC NERVE
POSTEROMEDIAL-ARTICULAR BR OF NERVE TO QUADRATUS FEMORIS
THUS FOR COMPLETE PAIN RELIEVE NEED TO BLOCK ALL THREE-
OBTURATOR,FEMORAL AND SCIATIC ARTICULAR BRANCHES.

67. Femoraln.withthreearticularbranches(arrow)

68. ABFN TECHNIQUE
LANDMARK-3-4 CM CAUDAL TO THE INGUINAL LIGAMENT
PROBE-LINEAR 6-13 MHZ
DRUG-20 ML 0.25 % BUPIVACAINE AND 4 MG DEXAMETHASONE
TECHNIQUE-OUT OF PLANE USG GUIDED
NEEDLE-3.5CM HYPODERMIC 23 G NEEDLE
IDENTIFICATION-IT’S A HYPERECHOIC TRIANGULAR TO OVAL
STRUCTURE,0.5-1 CM IN DIAMETER

69. REPRESENTATION OF ABFN AND ITS RELATION TO
MUSCLES AND FEMORAL VESSELS AND NERVE
SARTORIUS
RECTUS FEMORIS
A
B
F
A

70. SARTORIU
S
ILIACUS
RECTUS
FEMORIS
ARTICULATING
BRANCH OF
FEMORAL NERVE

71. SHAMROCK BLOCK
TRANSVERSE USG SCAN ,PROBE IS PLACED CRANIALLY TO THE ILIAC
CREST ,FOR LUMBAR PLEXUS BLOCK
FIRST DESCRIBED IN 2013 BY SAUTER ET AL
PSOAS MAJOR MUSCLE IS SEEN ANTERIOR TO THE TRANSVERSE
PROCESS,ERECTOR SPINAE IS POSTERIOR TO THE TRANSVERSE
PROCESS,QUADRATUS LUMBORAM IS AT THE APEX OF THE
TRANSVERSE PROCESS L4
EASILY RECOGNISABLE PATTERN OF SHAMROCK,THREE LEAVES IS SEEN
ON USG
DEPOSIT LA POSTERIOR TO THE PSOAS MAJOR MUSCLE.

75. The Shamrock lumbar plexus block: A dose-finding study.
Sauter AR1
, Ullensvang K, Niemi G, Lorentzen HT, Bendtsen TF, Børglum J, Pripp AH, Romundstad L.
Author information
Avolumeof20.4 mlropivacaine0.5%providedasuccessfulShamrocklumbarplexusblockin50%of
thepatients.Avolumeof36.0 mlwouldbesuccessfulin95%ofthepatients.

76. COSTOCLAVICULAR BLOCK
(PROXIMAL APPROACH OF
INFRACLAVICULAR BLOCK)
COSTOCLAVICULAR SPACE BOUNDARIES-deep and posterior to
middle of clavicle
ANTERIORLY-CLAVICLE
MEDIALLY-FIRST RIB
POSTERIORLY-SCALENUS ANTERIOR
LATERALLY-COSTOCLAVICULAR LIGAMENT AND SUBCLAVIUS MUSCLE
CONTENTS-
BRACHIAL NERVE PLEXUS
AXILLARY ARTERY
AXILLARY VEIN

80. COSTOCLAVICULAR BLOCK…

81. COSTOCLAVICULAR BLOCK…
ADVANTAGES-
AS COMPARED TO INFRACLAVICULAR FOSSA LATERALLY, HERE ALL
THREE CORDS ARE QUITE SUPERFICIAL AND CLUSTERED
TOGETHER,LATERAL TO AXILLARY ARTERY.
VERY RAPID ONSET SIMILAR TO SUPRACLAVICULAR BLOCK AND ALSO
LESS CHANCES OF SPARING OF THE LOWER TRUNK.
CATHETER CAN BE PLACED EASILY AND THAT TOO VERY CLOSE TOO
ALL THREE CORDS.
CATHETER DISPLACEMENT CHANCES ARE MINIMAL AS LIES DISTALLY
IN INTERMUSCULAR TUNNEL (SUBCLAVIUS AND SERRATUS ANTERIOR
MUSCLES).

82. TRANSVERSALIS FASCIA PLANE
BLOCKThe transversalis fascia plane block, or TFP block, is a truncal block that targets the L1 nerve
branches, namely the ilioinguinal and iliohypogastric nerves.
These nerves emerge from the lateral border of psoas major muscle, inferior to the 12th rib,
and course over the anterior surface of the quadratus lumborum muscle finally enter the
transversus abdominis plane between the internal oblique and transversus abdominis
muscles.
The TFP block targets the ilioinguinal and iliohypogastric nerves where they are between
the fascia of the transversus abdominis muscle and the transversalis fascia.
The fascia of the transversus abdominis muscle, also called the thoracolumbar fascia, is
formed when the transversus abdominis and internal oblique muscles taper off posteriorly
into a common aponeurosis.

83. TFP
INDICATIONS-
The TFP block is indicated for pain relief following anterior iliac crest bone
graft harvesting as the block is performed proximal to the L1 branches that
innervate the anterior iliac crest.
Local anesthetic spread can also involve the subcostal nerve (T12 spinal
nerve). This block is also an analgesic option for inguinal hernia repair, open
appendectomy and any surgery involving the L1 dermatome.

84. TFP V/S TAP
The TFP block is designed to block the L1 nerve branches, which the TAP block
does not reliably cover.
Local anesthetic is injected deep to the transversus abdominis muscle for the
TFP block versus superficial to the muscle for the TAP block.
The site of TFP injection is posterior to the mid-axillary line, unlike the classic
ultrasound-guided TAP block.

86. Internal Oblique Muscle
Transversus Abdominis Muscle
External Oblique Muscle
External oblique m usc
le
Internal oblique m usc
le
Transversus a bdominis
Quadratus l umborum

89. LOCAL INFILTRATION ANALGESIA-
LIA
Local infiltration analgesia (LIA) is an analgesic technique that has
gained popularity since it was first brought to widespread attention by
Kerr and Kohan in 2008.
The technique involves the infiltration of a large volume dilute
solution of a long-acting local anesthetic agent, often with adjuvants
(e.g., epinephrine, ketorolac, an opioid), throughout the wound at the
time of surgery.
The analgesic effect duration can then be prolonged by the placement
of a catheter to the surgical site for postoperative administration of
further local anesthetic.
The technique has been adopted for use for postoperative analgesia
following a range of surgical procedures (orthopaedic<knee and hip
surgeries>, general, gynecological, and breast surgeries).

90. Analgesic efficacy of local infiltration analgesia in hip and knee
arthroplasty: a systematic review
1. L. . Andersen
2. H. Kehlet
LIA provides effective analgesia in the initial postoperative
period after TKA in most randomized clinical trials even when
combined with multimodal systemic analgesia.
Local infiltration analgesia: a technique for the control of
acute postoperative pain following knee and hip surgery: a
case study of 325 patients.
Kerr DR1, Kohan L.
Local infiltration analgesia is simple, practical, safe, and
effective for pain management after knee and hip surgery.

91. LIA..ADVANTAGES
IT ALLOWS EARLY MOBILISATION.
IT SAVES THE HOSPITAL COSTS AS EARLY DISCHARGE.
INVOLVES NO COMPLICATIONS LIKE HYPOTENSION,QUADRICEPS MUSCLE
WEAKNESS,URINARY RETENTION ETC.
A NUMBER OF INVESTIGATORS HAVE FOUND LIA TO BE SUPERIOR TO
PLACEBO/NO INFILTRATION AND EPIDURAL ANALGESIA IN TERMS OF
POSTOPERATIVE ANALGESIA SCORES,JOINT FUNCTION/REHABILITATION,AND
LENGTH OF HOSPITAL STAY.
Peripheral nerve blockade (PNB) has been shown to provide equivalent
analgesia compared to epidural analgesia with the benefit of a lesser
incidence of hypotension and urinary retention , however PNB requires a
high level of expertise to perform,?QUADRICEPS WEAKNESS.
Choi et al. reviewed the use of epidural analgesia for pain relief following hip
(and knee) replacement in a Cochrane review in 2003 and concluded that the
beneficial effect of epidural analgesia was limited to 4–6 hours
postoperatively, and side effects (hypotension, pruritus, urinary retention)
were more frequent with epidural analgesia compared to systemic analgesia

93. OTHER NEWER TECHNIQUES IN
PAIN MEDICINEPostamputation residual limb pain is often a disabling chronic pain that is
refractory to current pain management modalities, such as medications,
peripheral nerve blocks or denervation,Using high-frequency alternating
current via a peripheral nerve cuff electrode creates a complete depolarizing
nerve block, which blocks painful or unwanted nerve transmission of pain
signals; the cuff is placed proximal to the neuroma at the end of the severed
nerve. This therapy yielded >50% pain reduction.More studies required.
PERCUTANEOUS FREEZING OF SENSORY NERVES PRIOR TO TKR
Percutaneous cryoneurolysis targeting the infrapatellar branch of the saphenous
nerve and anterior femoral cutaneous nerve could relieve post-operative knee
pain by temporarily blocking sensory nerve conduction. The treatment group
reported a statistically significant reduction in symptoms at the six-
and 12-week follow-up compared with the control group.More
studies are required.

94. PAIN MEDICINE…
Cryoanalgesia involves a cryogenic probe under direct fluoroscopy
guidance. A local anaesthetic is used in this procedure to numb the
skin and underlying tissues. A catheter is then inserted into this area.
A cryobrobe is threaded through the catheter. Once the specific nerve
area is identified, the freezing process begins(less than -20 degree
Celsius is effective). This can take 2-3 minutes and may be repeated
in order to cover one’s pain.
Cryoanalgesia can be utilized for treating small well localized lesions
of nerves, perineal pain, lower extremity pain, post-herpetic
neuralgia , and facial and cranial pain.
It has also been used to obtain pain relief in biomechanical pain
syndromes including lumbar or cervical facet syndromes, and
coccygodynia, and to treat post-surgical pain .
The most common use for cryoanalgesia for lower back pain is the
long term treatment of lumbar facet pathology.

96. PRACTICE MAKES A MAN AS WELL
AS A WOMAN PERFECT