0000000000280173
AUTHOR
Jose De Andres
Nerve Root and Types of Needles Used in Transforaminal Injections
The use of transforaminal epidural injections of steroids is common practice in pain medicine, in patients with radicular pain resistant to conventional treatments such as physiotherapy or anti-inflammatory medications. The goal of these injections is to deposit steroids in the proximity of nerve roots, using the epidural or the transforaminal route. The procedure is performed using a translaminar, caudal, or transforaminal approach.
Ultrastructure of the Perineurium
The perineurium is composed of multiple concentric single-cell layers enclosing individual nerve fascicles. Each layer has a thickness equivalent to the width of a perineurial cell. Groups of these cells join by means of tight junctions and desmosomes to form layers that function as a barrier against diffusion of particles across them. Perineurial internal layers have more of these specialized unions among perineurial cells, which are proximal to nerve fascicles.
Case series of fluoroscopic findings and 3D reconstruction of human spinal MRIs of the space of Okada.
Objective To better understand the unexpected spread of contrast medium observed by conventional fluoroscopic X-ray images during standard neuraxial techniques used in the treatment of pain. The support of 3D reconstruction of MRI images of structures within the lumbar spine was used to better understand the space of Okada. Methods Lumbar facet joint and epidural corticosteroid injections in five patients under fluoroscopic guidance with loss of resistance to air or saline to identify the facet joints or epidural space. Next, in a retrospective study, the authors examined the retrodural space of Okada and the neighboring tissues with 3D reconstruction of spinal MRIs of seven patients withou…
Clinical Characteristics, Patient-Reported Outcomes, and Previous Therapeutic Management of Patients with Uncontrolled Neuropathic Pain Referred to Pain Clinics
Background. The aim of this report was to evaluate the clinical profile and previous management of patients with uncontrolled neuropathic pain who were referred to pain clinics. Methods. We included adult patients with uncontrolled pain who had a score of ≥4 in the DN4 questionnaire. In addition to sociodemographic and clinical data, we evaluated pain levels using a visual analog scale as well as anxiety, depression, sleep, disability, and treatment satisfaction employing validated tools. Results. A total of 755 patients were included in the study. The patients were predominantly referred to pain clinics by traumatologists (34.3%) and primary care physicians (16.7%). The most common diagnos…
Hemodynamic impact of isobaric levobupivacaine versus hyperbaric bupivacaine for subarachnoid anesthesia in patients aged 65 and older undergoing hip surgery
Background The altered hemodynamics, and therefore the arterial hypotension is the most prevalent adverse effect after subarachnoid anesthesia. The objective of the study was to determine the exact role of local anesthetic selection underlying spinal anesthesia-induced hypotension in the elderly patient. We conducted a descriptive, observational pilot study to assess the hemodynamic impact of subarachnoid anesthesia with isobaric levobupivacaine versus hyperbaric bupivacaine for hip fracture surgery. Description Hundred twenty ASA status I-IV patients aged 65 and older undergoing hip fracture surgery were enrolled. The primary objective of our study was to compare hemodynamic effects based …
Increased Expression of AQP 1 and AQP 5 in Rat Lungs Ventilated with Low Tidal Volume is Time Dependent
BACKGROUND AND GOALS: Mechanical ventilation (MV) can induce or worsen pulmonary oedema. Aquaporins (AQPs) facilitate the selective and rapid bi-directional movement of water. Their role in the development and resolution of pulmonary oedema is controversial. Our objectives are to determine if prolonged MV causes lung oedema and changes in the expression of AQP 1 and AQP 5 in rats. METHODS: 25 male Wistar rats were subjected to MV with a tidal volume of 10 ml/kg, during 2 hours (n = 12) and 4 hours (n = 13). Degree of oedema was compared with a group of non-ventilated rats (n = 5). The expression of AQP 1 and AQP 5 were determined by western immunoblotting, measuring the amount of mRNA (prev…
Blocs nerveux périphériques, paresthésies et injections intraneurales
Resume Les fibres nerveuses, myelinisees ou non, sont disposees en faisceaux et entourees de plusieurs membranes l’endonerve, l’epinerve et la perinerve. La transmission de l’influx nerveux se fait de facon saltatoire d’un noeud de Ranvier a l’autre sur les fibres myelinisees et de facon continue sur les fibres non myelinisees. La compression ou le traumatisme d’un nerf produit une rafale de potentiels d’action que le patient interprete comme une paresthesie. Ce phenomene persiste tant que dure la lesion axonale. Les aiguilles a biseau court penetrent moins souvent la perinerve mais donne des lesions plus importantes dans ce cas. L’echoguidage montre que des injections intraneurales interfa…
COVID-19 psychological impact in 3109 healthcare workers in Spain: The PSIMCOV group
AbstractBackgroundThe current coronavirus disease (COVID-19) has a great impact worldwide. Healthcare workers play an essential role and are one of the most exposed groups. Information about the psychosocial impact on healthcare workers is limited.Methods3109 healthcare workers completed a national, internet-based, cross-sectional 45-item survey between 9 and 19 April 2020. The objective is to assess the psychological impact of the COVID-19 pandemic in Spanish healthcare workers. A Psychological Stress and Adaptation at work Score (PSAS) was defined combining four modified versions of validated psychological assessment tests (A) Healthcare Stressful Test, (B) Coping Strategies Inventory, (C…
Vulnerability of different nerves to intrafascicular injection by different needle types and at different approach angles: a mathematical model
Background and objectivesWe assume that intrafascicular spread of a solution can only occur if a large enough portion of the distal needle orifice is placed inside the fascicle. Our aim is to present and evaluate a mathematical model that can calculate the theoretical vulnerability of fascicles, analyzing the degree of occupancy of the needle orifice in fascicular tissue by performing simulations of multiple positions that a needle orifice can take inside a cross-sectional nerve area.MethodsWe superimposed microscopic images of two routinely used nerve block needles (22-gauge, 15° needle and 22-gauge, 30° needle) over the microscopic images of cross-sections of four nerve types photographed…
Pressure Monitoring of Intraneural an Perineural Injections Into the Median, Radial, and Ulnar Nerves; Lessons From a Cadaveric Study
Background: Nerve damage after regional anesthesia has been of great concern to anesthetists. Various modalities have been suggested to recognize and prevent its incidence. An understudied area is the measurement of intraneural pressure during peripheral nerve blockade. Previous investigations have produced contradicting results with only one study being conducted on human cadavers. Objectives: The purpose of this investigation was to systematically record intraneural and perineural injection pressures on the median, ulnar, and radial nerves exclusively as a primary outcome. Materials and Methods: Ultrasonography-guided injections of 1 mL of 0.9% NaCl over ten seconds were performed on phen…
Ultrastructure of Dural Lesions Produced in Lumbar Punctures
During lumbar puncture, the insertion of a single-use, short-beveled spinal needle produces a “tent-like” effect. The dura-arachnoid lesions produced by this Quincke type of needles show a “crescent moon” shape resembling the letter “U” or “V” (similar to the lid of a can), with clean-cut edges. As the needle tip advances, the cut fragment is folded inwards, while all dural and arachnoid layers are entirely severed and the edges of the lesion are displaced inwardly. As soon as the spinal needle is withdrawn, the edges of the lesion tend to retract, owing to the viscoelastic properties of the affected dura mater.
Injections of Particulate Steroids for Nerve Root Blockade: Ultrastructural Examination of Complicating Factors
Selective nerve root block by a transforaminal approach with radiological control allows injection of an appropriate corticosteroid next to the nerve root, although it has been associated with major neurological complications in a few cases. There have been several reports in which corticosteroid injections performed at the level of the cervical or lumbar spine have led to severe spinal cord ischemic infarction. These have occurred independently of whether the procedure was performed under radiological control, in which the tip of the needle is identified to prevent vascular spreading of the solution injected.
Ultrastructure of Spinal Dura Mater
Pia mater is the innermost of the three meningeal membranes, closely surrounding the brain, the spinal cord, and the portion of spinal nerve roots extending towards their exit across the dura mater. A cellular layer and a subpial compartment shape the structure of the pia mater. The cellular layer is made up of flat, overlapping pial cells with amorphous, fundamental substance interposed among them. The surface of the cellular plane appears smooth and bright under scanning electron microscopy (SEM). Transmission electron microscopy shows that the cellular component is about three to five pial cells thick at the medullary level and two to three cells thick at the level of the nerve roots. Th…
Updated management of occipital nerve stimulator lead migration: case report of a technical challenge
Abstract Electrode migration is a challenge, even with adequate anchoring techniques, due to the high mechanical stress on components of occipital nerve stimulation (ONS) for headache disorders. When a lead displacement of an ONS implant is diagnosed, there are currently different approaches described for its management. Nevertheless current neuromodulation devices are designed like a continuum of components without any intermediate connector, and if a lead displacement is diagnosed, the solution is the complete removal of the electrode from its placement, and its repositioning through an ex-novo procedure. The described technique can allow ONS leads to be revised while minimizing the need …
Expression of aquaporins 1 and 5 in a model of ventilator-induced lung injury and its relation to tidal volume
New Findings What is the central question of this study? Although different studies have attempted to find factors that influence the expression of aquaporins (AQPs) in the lung in different situations, to date no research group has explored the expression of AQP1 and AQP5 jointly in rats mechanically ventilated with different tidal volumes in a model of ventilator-induced lung injury. What is the main finding? Mechanical ventilation with a high tidal volume causes lung injury and oedema, increasing lung permeability. In rats ventilated with a high tidal volume, the pulmonary expression of AQP1 decreases. We analysed the expression of aquaporins 1 and 5 and its relation with tidal volume in…
The erector spinae plane block: a narrative review
Regional anesthesia and pain management have experienced advances in recent years, especially with the advent of fascial plane blocks. The erector spinae plane block is one of the newest techniques to be described. In the past two years, publications referring to ESP block have increased significantly. The objective of this review is to analyze the articles about ESP block that have been published to date. We performed a search in the main databases and identified 368 articles. After a selection of the relevant articles, 125 studies were found eligible and were included in the review. The ESP block is performed by depositing the local anesthetic in the fascial plane, deeper than the erector…
Impact of COVID-19 Pandemic on Anesthesia and Critical Care Residents in Spain.
Background: The pandemic caused by coronavirus disease 2019 (COVID-19) has substantially changed the activity in Spanish healthcare centers. Residents who face pandemics are vulnerable physicians with different knowledge and experience. Objectives: This study aimed to determine the impact of COVID-19 pandemic on the Anesthesia and Critical Care residents and to establish its formative and personal consequences. Methods: A 35-question digital survey was developed, and was distributed among Anesthesia and Critical Care residents in Spain. The quantitative variable "Objective Formative Impact Score" (PIOF) was defined, being proportional to the impact on formative routines. Results: Several pa…
The Neurostimulation Appropriateness Consensus Committee (NACC) Safety Guidelines for the Reduction of Severe Neurological Injury
Introduction Neurostimulation involves the implantation of devices to stimulate the brain, spinal cord, or peripheral or cranial nerves for the purpose of modulating the neural activity of the targeted structures to achieve specific therapeutic effects. Surgical placement of neurostimulation devices is associated with risks of neurologic injury, as well as possible sequelae from the local or systemic effects of the intervention. The goal of the Neurostimulation Appropriateness Consensus Committee (NACC) is to improve the safety of neurostimulation. Methods The International Neuromodulation Society (INS) is dedicated to improving neurostimulation efficacy and patient safety. Over the past tw…
Catheters in Regional Anesthesia
Anesthesiologists use different types of catheters in the performance of continuous regional anesthetic techniques such as epidural, subarachnoid, and paravertebral blocks, as well as peripheral nerve blocks.
Ultrastructure of Human Spinal Trabecular Arachnoid
The arachnoid trabecular layer, located internally to the arachnoid layer, is composed of fibers that form the spider web–like trabecular structure found in the subarachnoid space and in the adventitial layer of blood vessels. The arachnoid trabeculae give shape to tubular structures (arachnoid sheaths) for each nerve root and for the spinal cord. Some of these arachnoid trabeculae extend to the pia mater. The trabecular arachnoid is an extremely fragile structure, which can easily be damaged. Because of its fragility, this membrane may be destroyed during dissection and manipulation, so that it is not frequently seen or systematically described. Trabecular arachnoid limits nerve root movem…
3D interactive model of lumbar spinal structures of anesthetic interest
A 3D model of lumbar structures of anesthetic interest was reconstructed from human magnetic resonance (MR) images and embedded in a Portable Document Format (PDF) file, which can be opened by freely available software and used offline. The MR images were analyzed using a specific 3D software platform for biomedical data. Models generated from manually delimited volumes of interest and selected MR images were exported to Virtual Reality Modeling Language format and were presented in a PDF document containing JavaScript-based functions. The 3D file and the corresponding instructions and license files can be downloaded freely at http://diposit.ub.edu/dspace/handle/2445/44844?locale=en. The 3D…
Recomendaciones de uso de los anticoagulantes orales directos en el período perioperatorio
Because of the characteristics of direct oral anticoagulants (DOA), the lack of an antidote to completely reverse their anticoagulant effects, the absence of standardization in monitoring of their effects, and limited experience of their use, specific recommendations for their management in the perioperative period or in emergencies are required. In elective surgery, in patients with normal renal function and low hemorrhagic/ thrombotic risk, DOA should be withdrawn 2 days before the intervention; when the hemorrhagic/ thrombotic risk is higher, bridge therapy with a low molecular weight hepatin beginning 5 days before the intervention is proposed as an alternative. In emergency surgery, sy…
Trends in Incidence and Transmission Patterns of COVID-19 in Valencia, Spain
Importance Limited information on the transmission and dynamics of SARS-CoV-2 at the city scale is available. Objective To describe the local spread of SARS-CoV-2 in Valencia, Spain. Design, Setting, and Participants This single-center epidemiological cohort study of patients with SARS-CoV-2 was performed at University General Hospital in Valencia (population in the hospital catchment area, 364 000), a tertiary hospital. The study included all consecutive patients with COVID-19 isolated at home from the start of the COVID-19 pandemic on February 19 until August 31, 2020. Exposures Cases of SARS-CoV-2 infection confirmed by the presence of IgM antibodies or a positive polymerase chain reacti…
Opioid less perioperative care.
Opioids are the most frequently administered analgesics in the perioperative period. The analgesic potency of opioids is without question. While the opioid- free or opioid-less perioperative care concept is not a reality in most surgical centers of the United States and other developed countries, there is a significant number of healthcare problems (i.e. adverse events, opioid-induced hyperalgesia and opioid diversion) related to the indiscriminate use of opioids that warrants the implementation of multimodal analgesia strategies. Although it has been suggested an association between the use of opioids and cancer progression, there is a need of well-designed studies to confirm that associat…
Injection pressure mapping of intraneural vs. perineural injections: further lessons from cadaveric studies.
Background The aim of the study was to investigate the difference between intraneural and perineural injection pressures in human cadavers. Targeted nerves included the cervical roots, the supraclavicular and infraclavicular brachial plexus, the sciatic-subgluteal nerve and the common peroneal and tibial nerves. Methods Ten readings were obtained for each nerve location. Over ten seconds, 1 mL of 0.9% NaCl was injected - deliberately slower than in clinical practice to eliminate the risk of aberrant readings relating to the speed of injection. Perineural injections occurred at least 1 mm outside the epineurium. After pressure recordings were completed 0.1mL of dye was injected, and dissecti…