Search Results (57)

Peripheral nerve blocks can effectively reduce the use of general anesthesia and opioids in situations where robust pain management is critical, such as severe extremity trauma and hip, femur, and knee surgeries. Despite these benefits, nerve blocks are underutilized due to the high skill required to accurately insert a needle and safely deliver local anesthetic. To overcome this challenge, ultrasound image guidance enabled by artificial intelligence (AI) offers a semi-automated solution for regional anesthesia delivery by non-specialists. As a first step towards realizing an integrated platform for AI-guided nerve blocks, the main objective of this study is to develop and characterize deep learning algorithms to interpret anatomical landmarks on ultrasound images in real time and identify aimpoints for needle placement. Our AI system was trained on over 55,000 images from 20 porcine models and demonstrated an average area under the precision–recall curve of 0.92 (SD = 0.03) for in vivo landmark detection in the femoral nerve region. In prospective live animal testing, aimpoint identification had a 98.3% success rate with an average time of 40.5 s (SD = 33.5). Future work will focus on integrated testing with handheld robotics towards a more accessible method for delivering regional anesthesia in settings from point of injury to medical transport to hospitals. Full article

Background: Meralgia paresthetica is a neuropathic pain syndrome caused by compression of the lateral femoral cutaneous nerve (LFCN). While often self-limited, a subset of patients develops persistent symptoms requiring interventional management. Ultrasound guidance has improved accuracy and safety in peripheral nerve blocks, but evidence from Internal Medicine-led procedures remains limited. Methods: We performed a retrospective, observational case series including all patients aged ≥17 years who underwent ultrasound-guided LFCN blocks at Virgen del Rocío University Hospital between 2016 and 2024. Demographic data, comorbidities, procedural details, complications, and clinical outcomes were collected. Symptomatic response and recurrence were assessed descriptively. Results: Eleven patients were included (10 women; median age 56 years). The most frequent comorbidities were obesity (45.5%) and type 2 diabetes mellitus (18.2%). Clinical improvement following LFCN block was achieved in 10 of 11 patients (91%). Three patients (27%) experienced recurrence, with a median time to recurrence of 24 months; two underwent a second successful block, and one showed spontaneous resolution. No major complications occurred, and only one patient developed a mild, self-limited local reaction. Conclusions: Ultrasound-guided LFCN block is a safe, well-tolerated, and highly effective intervention for patients with persistent meralgia paresthetica. Outcomes achieved by an Internal Medicine specialist appear consistent with previously published reports from anesthesiology settings, underscoring the value of point-of-care ultrasound as a practical and precise tool for managing neuropathic pain within Internal Medicine settings. Full article

Background and Clinical Significance: Sickle cell vaso-occlusive crisis (VOC) may present with severe refractory pain that is difficult to control despite guideline-directed multimodal therapy and high-dose opioids. Case Presentation: We report an adult with VOC and severe, opioid-refractory anterior thigh and leg pain who was treated with bilateral, ultrasound-guided continuous femoral nerve catheters (0.5% bupivacaine bolus per side followed by infusion of 0.2% ropivacaine at 5 mL/h each). Twenty-four-hour opioid use decreased by 76% from 44 mg intravenous hydromorphone (880 MME) before block placement to 10.4 mg (208 MME) after catheter initiation. Pain scores declined significantly from 10/10 to 3/10, facilitating mobilization and expediting discharge of the patient. No local anesthetic systemic toxicity occurred, and transient quadriceps weakness was managed with fall-risk precautions. IRB approval for this case report was waived per our institution policy. Conclusions: In select adults with VOC and predominant anterior thigh/leg pain, bilateral continuous femoral nerve catheters may provide rapid analgesia and substantial opioid-sparing benefits as part of multidisciplinary care. These findings are hypothesis-generating and support prospective evaluation of continuous peripheral nerve block strategies in VOC. Full article

Total knee arthroplasty (TKA) is one of the most performed surgical procedures in the United States and is often associated with moderate to severe postoperative pain. Multimodal postoperative analgesia following TKA is essential for optimizing postoperative recovery and enabling early postoperative mobilization. Regional anesthesia using ultrasound-guided peripheral nerve blocks plays an important part in perioperative pain management by targeting the femoral, obturator, and sciatic nerves of the knee joint. A variety of peripheral nerve block techniques have been described, which can be classified as either motor-blocking or motor-sparing techniques. Traditional motor-blocking regional anesthesia techniques, such as femoral and sciatic nerve blocks, provide excellent analgesia but can result in significant quadriceps weakness that delays ambulation after TKA. Motor-sparing regional anesthesia techniques, including the adductor canal block, iPACK block, and genicular nerve block, are becoming more widely used in enhanced postoperative recovery protocols for outpatient and short-stay inpatient TKAs. The peripheral nerve block technique can be selected according to the type of surgical procedure, the planned length of stay, rehabilitation goals, and patient comorbidities. Multiple peripheral nerve blocks provide better analgesia than single-injection blocks, and continuous catheter techniques are used for prolonging analgesia in select patients. An individualized multimodal regional anesthesia approach should be utilized to maximize analgesia after TKA to optimize postoperative outcomes. We present a narrative review of peripheral nerve block techniques and strategies for their use following inpatient or outpatient TKA. Full article

Background and Objectives: Regional anesthesia is one of the critical alternatives for managing severe pain in patients with hip fractures. Femoral nerve block (FNB) is a common technique, and pericapsular nerve group block (PENG) has emerged as a promising alternative. However, the comparative efficacy of these techniques in extracapsular hip fractures, which have a distinct innervation pattern from intracapsular fractures, is not well established. Thus, we compared the analgesic efficacy of ultrasound-guided FNB and PENG blocks in emergency department (ED) patients with extracapsular hip fractures. Methods: This single-center, retrospective observational study was conducted from 1 January 2020 to 31 July 2021. We included adult patients presenting to the ED with an acute, isolated extracapsular hip fracture who received FNB or PENG. The primary outcome was pain reduction, analyzed by pain trajectory analysis according to the pain intensity difference (PID) at multiple time points (0, 15, 30, 60, and 120 min) and a time-to-event analysis for meaningful pain relief (PID ≥ 4). Secondary outcomes included rescue morphine consumption, ED length of stay (LOS), and hospital LOS. Results: Thirty-nine patients were included (21 FNB; 18 PENG). The FNB group demonstrated a significantly greater reduction in pain scores over time than the PENG group (likelihood ratio test p < 0.001). In the time-to-event analysis, median time to meaningful pain relief was 1 min in the FNB group versus 114 min in the PENG group. Cox proportional hazards modeling demonstrated that the FNB group achieved meaningful pain relief 2.40 times faster than the PENG group (HR = 2.40, 95% CI = 1.06–5.44, p = 0.03). There were no significant differences between the groups in rescue morphine use, ED LOS, or hospital LOS after multivariable adjustment. Conclusions: In this retrospective observational study of patients with extracapsular hip fractures, FNB was associated with more rapid and effective pain relief than PENG. These findings suggest that FNB may be considered a favorable regional analgesic technique for these patients, though prospective randomized trials are needed to establish definitive treatment recommendations. Full article

Background and objectives: Anterior cruciate ligament reconstruction (ACLR) is often associated with significant postoperative pain. Effective pain control is vital for early mobilization and reducing opioid use. While femoral nerve block (FNB) and adductor canal block (ACB) are common, they can cause motor weakness and incomplete analgesia. The genicular nerve block (GNB), typically used for chronic knee pain and arthroplasty, may offer a motor-sparing alternative for ACLR pain management. This review evaluates the evidence on GNB’s effectiveness for pain control, opioid reduction, and recovery after ACLR. Materials and Methods: A literature search (January 2014–May 2025) identified five studies involving adult ACLR patients receiving GNB. Data on demographics, techniques, pain scores, opioid use, and complications were analyzed. Results: Among 115 patients, GNB provided effective analgesia and reduced opioid needs. Randomized trials showed GNB was comparable to ACB and more effective when combined. Ultrasound, especially with Doppler, enhances precision and safety. No major motor deficits or adverse events were noted. Landmark-based approaches also showed utility in low-resource settings. Conclusions: GNB is a promising, motor-sparing option for postoperative pain in ACLR. Further high-quality trials are needed to confirm the benefits and standardize its use. The findings should be interpreted with caution, as the current evidence is of limited quality and lacks generalizability. Full article

Objectives: This study investigates the effectiveness of dexamethasone when utilized as an adjunct agent in enhancing the outcomes of a pericapsular nerve group (PENG) block compared to its systemic administration for managing pain in patients having surgery for femoral fractures. Methods: This study enrolled 44 patients who received a PENG block following spinal anesthesia. Two groups were formed by stratifying the patients, involving those in whom dexamethasone was received through perineural administration (Group P, n = 22) and those in whom it was received through systemic administration (Group S, n = 22). Information concerning the demographic features of the patients, along with operative and postoperative details, was meticulously documented for analysis. The patients’ pain levels were recorded using the numerical rating scale (NRS) at multiple time points. Results: In the perineural dexamethasone group, the length of time of sensory and motor blockade and the time elapsed until the initial analgesic requirement were longer (p < 0.001). The consumption of tramadol and the pain scores measured were noted to be decreased. (p < 0.001). There were no notable distinctions regarding patient mobilization or the length of inpatient stay. Conclusions: The perineural administration of dexamethasone in PENG block procedures may provide more effective analgesia for surgeries involving femoral neck fractures. By minimizing the use of systemic opioids, it may also help mitigate potential side effects. These findings indicate that perineural dexamethasone could serve as a beneficial adjuvant agent for patients undergoing femoral neck fracture surgeries. Full article

Background and Objectives: Ultrasound (US)-guided peripheral regional anesthesia (pRA) is gaining increasing importance in emergency medicine as an effective, low-ridsk alternative to general anesthesia (GA), procedural sedation (PS), or opioid therapy. By enabling rapid, direct pain management in the emergency department (ED), pRA can help preserve scarce surgical and anesthetic resources and, in some cases, avoid inpatient admissions. The aim of this study was to analyze the indications, techniques, and clinical impact of pRA in the orthopedic-focused ED of an affiliated hospital. Materials and Methods: All pRA and PS procedures performed over a six-year period were retrospectively reviewed among 35,443 orthopedic-trauma emergency patients. pRA was carried out under US guidance with standardized monitoring. Diagnoses, block techniques, effectiveness, and complications were analyzed descriptively. Results: A total of 1292 patients (3.7%) underwent either pRA (n = 1117; 3.2%) or PS (n = 175; 0.5%). pRA was performed in 22% of cases for interventions such as reductions or extensive wound management. In 78%, pRA was applied for analgesia, for example, in the diagnostic work-up and treatment of non-immediately operable fractures, lumbago, or arthralgia. The most common pRA techniques were brachial plexus blocks (54%) and femoral nerve blocks (25%). Fascial plane blocks (6.1%) and paravertebral blocks (1.5%) were rarely used. PS was performed in 175 of 1292 patients (13%), although pRA would have been feasible in 159 of these cases. No complications of pRA were observed, and GA could routinely be avoided. Conclusions: US-guided pRA proved to be an effective and safe alternative to PS, GA, or systemic analgesia for selected indications, allowing immediate treatment without the need for operative capacities. To ensure safe application, these techniques should be an integral part of the training curriculum for ED personnel. Full article

Background: Multimodal analgesia, combining adductor canal block (ACB) and local infiltration analgesia (LIA), is commonly used for pain control after total knee arthroplasty (TKA). However, ACB alone may not fully cover the anteromedial knee, a region extensively disrupted by TKA. Recent studies suggest that blocking branches of the anterior femoral cutaneous nerve (AFCN) could enhance analgesia, but targeted AFCN blocks are technically challenging. We evaluated supra-sartorial subcutaneous infiltration (SSSI) at the femoral triangle apex as a simpler alternative to AFCN blocks. Methods: We retrospectively reviewed 19 patients undergoing TKA with a standardized multimodal analgesic protocol, including intraoperative LIA limited to posterior capsule (PC-LIA), postoperative SSSI, and delayed intermittent ACB via catheter. SSSI involved infiltrating 20 mL of 0.3% ropivacaine into the subcutaneous plane above the sartorius muscle at the level of femoral triangle apex. Pain was assessed using Numerical Rating Scale (NRS) scores at rest and during movement at 9:00 PM on postoperative day 0 (POD 0) and 9:00 AM on POD 1, with scheduled ACB doses administered at the time of NRS pain score assessments. Rescue ACB boluses were given for intolerable pain before the first scheduled dose. Results: Eleven patients (58%) required no rescue analgesia before the first scheduled ACB, maintaining NRS scores ≤ 4 at rest and with movement for a minimum of 575–785 min post-spinal anesthesia. Eight patients needed rescue ACB, with variable pain relief. Conclusions: SSSI, when combined with PC-LIA, provided clinically meaningful analgesia in 58% of our patient cohort following TKA, though the variability observed suggests limited consistency. As a practical alternative to targeted AFCN blocks, SSSI could potentially complement ACB in multimodal pain management, but its efficacy remains uncertain due to the retrospective, non-controlled study design without a comparator group. Further investigation through prospective randomized controlled trials is warranted to validate these preliminary findings. Full article

Pediatric hip surgeries are associated with moderate to high levels of pain, which, in severe cases can lead to opioid prescription and use. There is a growing focus on reducing post-operative pain in these patients to decrease the need for opioids, as well as increase early mobilization for recovery. Conventional methods of pain relief using opioids can have unwanted negative impacts on pediatric patients such as respiratory depression, nausea, confusion, and the concerning possibility for the development of dependence. Likewise, traditional methods of anesthesia, like the lumbar epidural block, can have unwanted systemic side effects, such as hypotension, urinary retention, arrhythmias, and spinal abscesses. These complications can lead to longer hospital stays and delayed recovery. This review analyzes the efficacy of a newer regional anesthesia technique, the pericapsular nerve group (PENG) block, in comparison to the lumbar epidural block. This technique utilizes precision-based anesthesia to selectively block the articular branches to the hip joint while avoiding the main trunks of the femoral and obturator nerves. Additionally, with the utilization of high-resolution ultrasound to guide the blocks, providers can increasingly count on proper insertion and predictable anesthetic spread. The result is a motor-sparing blockade that shows promise in allowing earlier mobilization and better functional recovery times after pediatric hip surgeries. Full article

Background: Stiff-knee gait commonly involves rectus femoris spasticity in patients with central nervous system lesions. Diagnostic nerve blocks aid in predicting treatment outcomes; however, current techniques may overlook multiple nerve branches that innervate the rectus femoris muscle, potentially resulting in an incomplete assessment of treatment outcomes. Methods: We present an ultrasound-guided approach that we currently use in our practice, using anatomical landmarks, including the femoral artery, the sartorius muscle, and the rectus femoris’ characteristic “J-shaped” internal tendon. The technique employs an “elevator” scanning method to identify all motor nerve branches (typically 2–3) entering the proximal third of the rectus femoris muscle. Each branch is blocked using an in-plane needle approach with 1–2 mL of 2% lidocaine. Results: The technique enables the visualization of hyperechoic nerve branches entering the rectus femoris muscle from medial to lateral, sometimes accompanied by small vascular branches that are identifiable with a Doppler ultrasound. Optimal ultrasound settings include probes >8 MHz, appropriate focus positioning, and dynamic range < 60 dB. The multi-branch approach produces rapid-onset motor weakness (5–10 min). Conclusions: This comprehensive multi-branch rectus femoris nerve block technique may enhance diagnostic accuracy for spasticity assessment, potentially leading to more informed treatment selection for stiff-knee gait. Full article

Background: Hip fractures represent a major clinical challenge, particularly in elderly and frail patients, where postoperative pain control must balance effective analgesia with motor preservation to facilitate early mobilization. Various regional anesthesia techniques are used in this setting, including the pericapsular nerve group (PENG) block, fascia iliaca compartment block (FICB), femoral nerve block (FNB), and quadratus lumborum block (QLB), yet optimal strategies remain debated. Objectives: To systematically review the efficacy, safety, and clinical applicability of major regional anesthesia techniques for pain management in hip fractures, including considerations of fracture type, surgical approach, and functional outcomes. Methods: A systematic literature search was conducted following PRISMA 2020 guidelines in PubMed, Scopus, Web of Science, and the virtual library of the Hospital Central de la Defensa “Gómez Ulla” up to March 2025. Inclusion criteria were RCTs, systematic reviews, and meta-analyses evaluating regional anesthesia for hip surgery in adults. Risk of bias in RCTs was assessed using RoB 2.0, and certainty of evidence was evaluated using the GRADE approach. Results: Twenty-nine studies were included, comprising RCTs, systematic reviews, and meta-analyses. PENG block demonstrated superior motor preservation and reduced opioid consumption compared to FICB and FNB, particularly in intracapsular fractures and anterior surgical approaches. FICB and combination strategies (PENG+LFCN or sciatic block) may provide broader analgesic coverage in extracapsular fractures or posterior approaches. The overall risk of bias across RCTs was predominantly low, and certainty of evidence ranged from moderate to high for key outcomes. No significant safety concerns were identified across techniques, although reporting of adverse events was inconsistent. Conclusions: PENG block appears to offer a favorable balance of analgesia and motor preservation in hip fracture surgery, particularly for intracapsular fractures. For extracapsular fractures or posterior approaches, combination strategies may enhance analgesic coverage. Selection of block technique should be tailored to fracture type, surgical approach, and patient-specific functional goals. Full article

Background: Effective postoperative pain management is essential in femoral limb lengthening surgery. Although regional nerve blocks reduce pain and opioid use, their benefit in antegrade femoral intramedullary limb lengthening is unclear. This study compares postoperative pain and opioid consumption in patients receiving general anesthesia (GA) alone versus GA with a preoperative femoral or fascia iliaca nerve block. Methods: A retrospective review included 192 patients who underwent femoral lengthening with intramedullary telescoping nails between January 2012 and October 2023 at a single center. Patients were categorized into Group A (GA alone, n = 131) and Group B (GA plus nerve block, n = 61). Primary outcomes were postoperative mean and maximum pain scores in the first 24 h, total opioid pills prescribed at discharge, and total morphine milligram equivalents (MMEs) used in the Post-Anesthesia Care Unit (PACU). Non-inferiority was defined by a margin of one standard deviation for pain scores and opioid usage. Results: Demographics were similar between groups. Maximum PACU pain scores were 3.8 for Group A and 3.3 for Group B (p > 0.05); mean pain scores were 2.1 and 1.9, respectively (p > 0.05). GA alone was non-inferior for pain control. However, total opioid pills prescribed at discharge were higher in Group A (23.2) than Group B (10) (p < 0.05). PACU MME usage was also higher in Group A (26 vs. 18.4 ± 15 mg, p < 0.05), though non-inferiority criteria were met. Conclusions: GA alone is non-inferior to GA with nerve block for postoperative pain management following antegrade femoral intramedullary limb lengthening. Although patients without a nerve block received more opioids at discharge, their pain control remained similarly effective. Given potential risks and the lack of clear pain reduction benefits, routine nerve block use may not be warranted. Decisions regarding nerve block application should be individualized, considering patient preferences, surgeon recommendations, and anesthesiologist input. Full article

Background: Total hip arthroplasty (THA) improves the quality of life by alleviating pain and restoring function. The optimal pain control with minimal muscle weakness is paramount for early rehabilitation and for reducing complications. Although PROSPECT and ICAROS guidelines recommend the Fascia Iliaca Compartment Block (FICB), it is associated with insufficient pain relief and a prolonged quadriceps motor block. The association of the PENG (Pericapsular Nerve Group) with LFCN (lateral femoral cutaneous nerve) blocks may address these limitations, provide improved motor-sparing pain control, and offer a more tailored approach that enhances both an early postoperative recovery and patient satisfaction. Methods: A randomized controlled trial (November 2023–July 2024) compared the PENG + LFCN to the FICB in patients undergoing elective THAs under spinal anesthesia. The primary outcome was quadriceps weakness at 6 h post-block. Secondary outcomes included the degree of hip flexion and pain scores at 6, 24, and 48 h post-block, opioid consumption, and time to ambulation. Results: Fifty-eight patients were randomized (twenty-nine per group). The PENG + LFCN group achieved a significantly greater muscle strength (MRC: 4 [4; 4] vs. 3 [3; 4], p < 0.0001) and better hip flexion at all measured moments (6 h: 45° [37; 60] vs. 30° [25; 43], 24h: 59° [49; 66] vs. 47° [36; 50], 48 h: 62° [55; 70] vs. 50° [40; 55], all p < 0.0001). Resting pain was lower in the PENG + LFCN group (0 [0; 1], 0 [0; 2], and 0 [0; 1] vs. 2 [0; 3], 1 [0; 3], 1 [0; 3]), as was the dynamic pain during movement (1 [0; 2], 2 [2; 4], and 2 [1; 2] vs. 3 [2; 5], 3 [2; 4], and 3 [1; 3]; all p < 0.001), along with a lower total opioid consumption (0 [0; 0] vs. 7.5 [7.5; 22.5] MME, p < 0.001). Conclusions: The PENG + LFCN block outperformed the FICB in muscle strength, hip flexion, pain control, and opioid use, suggesting it may be a more effective option for THAs. Full article

The evolution of regional anesthesia in total hip arthroplasty (THA) has significantly impacted perioperative management, particularly in older adults, where age-related physiological vulnerability requires optimized strategies. Adequate pain control is crucial in enhancing recovery, minimizing opioid consumption, and reducing complications. Traditional nerve blocks such as lumbar plexus and femoral nerve blocks have long been the mainstay of analgesia. However, they are associated with significant motor impairments, which delay mobilization and increase the fall risks. Introducing motor-sparing regional anesthesia techniques represents a substantial advancement in optimizing postoperative pain management while preserving muscle function. Motor-sparing techniques, including the pericapsular nerve group (PENG) block, supra-inguinal fascia iliaca block (SI-FIB), erector spinae plane block (ESPB), and quadratus lumborum block (QLB), have been developed to provide adequate analgesia without compromising motor control. The PENG block selectively targets the articular branches of the femoral, obturator, and accessory obturator nerves, ensuring superior pain relief while minimizing quadriceps weakness. Similarly, the SI-FIB provides extensive sensory blockade with minimal motor involvement, allowing for earlier ambulation. The ESPB and QLB extend analgesia beyond the hip region while preserving motor function, reducing opioid consumption, and facilitating early rehabilitation. Compared to traditional motor-impairing blocks, these newer techniques align with Enhanced Recovery After Surgery (ERAS) protocols by promoting early mobility and reducing the hospital length of stay. Studies suggest that motor-sparing blocks lead to improved functional recovery, lower postoperative pain scores, and decreased opioid requirements, which are critical factors in geriatric THA patients. Moreover, these techniques present a safer alternative, reducing the risk of postoperative falls—a significant concern in elderly patients undergoing hip replacement. Despite their advantages, motor-sparing nerve blocks are still evolving, and further research is necessary to standardize the protocols, optimize the dosing strategies, and evaluate the long-term functional benefits. Integrating these techniques into routine perioperative care may significantly enhance patient outcomes and revolutionize pain management in geriatric THA. As regional anesthesia advances, motor-sparing techniques will improve postoperative recovery, ensuring patient safety and functional independence. Full article