Search Results (660)

Background/Objectives: Large language models (LLMs) are increasingly used for patient education, yet comparative evidence regarding their accuracy, safety, and ethical performance remains limited, particularly in high-risk fields such as anesthesiology. This study aimed to conduct a multidimensional comparison of five contemporary LLMs in answering common patient questions in anesthesiology. Methods: In this cross-sectional, comparative in silico study, 30 standardized patient questions covering general anesthesia, spinal/epidural anesthesia, and peripheral nerve blocks were submitted to ChatGPT, Gemini, Microsoft Copilot, DeepSeek, and Grok. Responses were independently evaluated under full blinding by five senior anesthesiology professors using a 5-point Likert scale across six domains: accuracy, safety, completeness, understandability, ethics, and overall assessment. Inter-rater reliability was assessed using intraclass correlation coefficients (ICC). Performance differences were analyzed using linear mixed-effects models accounting for question- and evaluator-level variability, with results reported as estimated marginal means. Results: Inter-rater agreement was good to excellent across all domains (ICC > 0.75). Significant model-related differences were observed for overall assessment, accuracy, safety, completeness, and ethics (all p < 0.001), whereas understandability did not differ significantly between models. ChatGPT achieved the highest overall performance, while Gemini demonstrated superior accuracy. Model performance varied across anesthesiology subspecialties, with significant model × topic interactions identified in multiple domains (p < 0.01). Conclusions: LLMs may serve as supportive tools for patient education in anesthesiology; however, their performance varies substantially across models and clinical contexts. Differences in accuracy, safety, and ethical performance highlight the need for cautious, context-aware integration of LLMs into clinical practice rather than their use as substitutes for anesthesiologists’ clinical judgment. 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: The infraclavicular brachial plexus block is a widely used regional anesthesia technique for surgery of the distal upper limb. Although generally considered safe—particularly with ultrasound guidance—a range of vascular, neurological, respiratory, and anesthetic-related complications continues to be reported. Understanding how anatomic factors can influence the occurrence of these events is essential for improving procedural safety. Objective: This narrative review aims to correlate clinically reported complications of the infraclavicular block with underlying anatomical mechanisms that may predispose to their development. Methods: A narrative review of the literature was conducted using PubMed, Scopus and Web of Science to identify clinical studies, observational series, and case reports published between 1995 and 2025 that documented complications associated with infraclavicular brachial plexus block in adults. Publications were selected based on relevance to vascular, neurological, respiratory, infectious, and local anesthetic systemic complications. Findings were synthesized descriptively, with emphasis on anatomical-clinical correlations rather than quantitative meta-analysis. Results: Reported complications include vascular puncture and hematoma formation, transient or persistent neurological deficits, Horner’s syndrome, hemidiaphragmatic paralysis, pneumothorax, local anesthetic systemic toxicity, and infectious complications. The incidence of these events varies widely across studies, reflecting differences in block technique, use of ultrasound guidance, injected anesthetic volume, and operator experience. Anatomical factors—such as the close relationship of the cords of the brachial plexus to the axillary vessels and the continuity of fascial planes—provide plausible explanations for these variations. Conclusions: Most complications of the infraclavicular block can be understood and anticipated through careful consideration of regional anatomy. Integrating anatomical knowledge with ultrasound guidance and optimized injection strategies may substantially reduce the risk of adverse events. This review highlights key anatomical mechanisms underlying reported complications and outlines practical implications for clinical practice. Full article

Background: Effective pain control is fundamental in pediatric dentistry. Supraperiosteal infiltration (SPA) and inferior alveolar nerve block (IANB) are the most used local anesthesia (LA) techniques. This review evaluated the available evidence on intraligamentary anesthesia (ILA) to assess its efficacy, safety, and viability as an alternative to conventional techniques. Methods: The review protocol was registered in PROSPERO (CRD420261284494) and conducted in accordance with PRISMA guidelines. Three databases were searched for RCTs published in English after 2000 involving children. Studies that compared ILA, delivered via either traditional or computer-controlled systems (CC-ILA), with other LA techniques were included. Risk of bias was assessed using the Cochrane’s RoB 2.0 tool. Meta-analysis was performed using a random-effects model with Stata/SE 18.0. Results: The database search yielded 347 records; after duplicate removal, 153 articles were screened. Thirty-four papers were assessed, of which thirteen studies were included, and three were retained for the meta-analysis. Significantly lower pain perception and improved physiological parameters were reported with ILA compared with IANB. CC-ILA demonstrated greater efficacy and reduced procedural discomfort than conventional ILA. Patients favored CC-ILA over IANB (68.0% vs. 32.0%). Postoperative lip biting occurred more frequently following IANB and CC-SPA than after ILA. Overall risk of bias was low. Meta-analysis revealed no significant difference in pain perception between ILA and IANB (z = −0.26; p = 0.79). Conclusions: ILA, particularly CC-ILA, appears to be an effective, safe, and well-tolerated technique and may be considered a valid anesthetic option in pediatric dentistry. The review did not receive any funding. Full article

Background/Objectives: Neurofibromatosis Type 1 (NF1) is a genetic syndrome caused by pathogenic NF1 variants encoding neurofibromin, a Ras GTPase activating protein. Individuals with NF1 develop peripheral nerve sheath tumors called neurofibromas. Approximately 50% of NF1 patients develop plexiform neurofibromas (pNFs) which have up to 13% lifetime risk of transformation into malignant peripheral nerve sheath tumors (MPNSTs). Current therapeutic strategies emphasize surgical resection with wide margins, radiation, and traditional chemotherapy for unresectable MPNSTs. However, NF1 patients diagnosed with MPNSTs have 5-year survival rates as low as 16%. The two recently FDA-approved drugs for pNFs, the MEK inhibitors selumetinib and mirdametinib, are not used to prevent or treat MPNSTs. Methods: The MEK inhibitor trametinib and the dual HDAC/PI3K inhibitor fimepinostat were assessed for growth inhibitory effects in nine unique patient-derived MPNST cell lines, as both drugs have preclinical efficacy in other Schwann cell-derived tumors. Results: Trametinib, which is approved for malignant melanomas, promoted cell death in 7/9 MPNST cell lines with a geometric mean GI50 = 17 nM. When directly compared to selumetinib and mirdametinib in a subset of four MPNST cell lines, trametinib had the lowest mean GI50 (trametinib = 38 nM, mirdametinib = 1.6 µM, selumetinib = 4.9 µM). Trametinib was also superior to selumetinib and mirdametinib in blocking ERK1/2 phosphorylation for 24 h. Fimepinostat promoted cell death in all cell lines with a geometric mean GI50 = 17 pM. Conclusions: These studies demonstrate in vitro efficacy for two candidate MPNST therapeutics which could reduce tumor burden and metastasis in NF1 patients. Full article

Background/Objectives: Total knee arthroplasty (TKA) is associated with severe postoperative pain that can impair early mobilization and prolong recovery. While adductor canal block combined with iPACK is commonly recommended, this strategy may provide incomplete articular coverage and occasionally compromise quadriceps function. Genicular nerve block (GNB) selectively targets the sensory innervation of the knee, and when combined with iPACK may achieve near-complete joint analgesia while preserving motor function. This case series aimed to evaluate the magnitude and duration of analgesia and functional recovery provided by a four-nerve GNB combined with iPACK. Methods: Five patients undergoing unilateral TKA under spinal anesthesia received ultrasound-guided blocks of the superolateral, superomedial, inferomedial genicular nerves and the nerve to vastus intermedius, together with an iPACK block. Ropivacaine combined with dexamethasone and dexmedetomidine was used. The primary outcome (pain intensity) [Numeric Rating Scale, NRS] and secondary outcomes (time to first rescue analgesia, opioid consumption, range of motion, and complications) were recorded up to 72 h postoperatively within a standardized multimodal analgesic protocol. Results: Pain scores at rest and on movement remained consistently below 3/10 in all patients. Three patients required no rescue analgesia, while two required a single dose at 36–40 h. Knee range of motion exceeded 90° in all cases, and early mobilization was achieved without quadriceps weakness. No neurological or systemic adverse events occurred. Conclusions: Four-nerve genicular block combined with iPACK, enhanced with perineural adjuncts, provided prolonged, opioid-sparing analgesia with preserved motor function after TKA. This joint-selective, motor-sparing strategy warrants further evaluation in randomized trials. Full article

Introduction: Reliable identification regarding interfascial spaces proves essential to achieve successful nerve block analgesia; however, ultrasound guided approaches are recognized as challenging, particularly in obese or pediatric patients. In prior cadaveric and clinical investigations, multiple approaches were evaluated to identify methods for measuring injection pressures as a function of needle position relative to fascia. Our previous study proposed simpler method of finding interfascial spaces with the needle tip. In this study, it was examined whether needle tip design influences injection pressures during regional anesthesia procedures, via an ex vivo pig specimen setup. Methods: A bespoke apparatus for tracking injection pressure was deployed to enable continuous measurement of intraluminal pressure generated while delivering saline throughout ultrasound guided peripheral nerve block needles conducted within pig thigh specimens. Delivery was performed using an infusion pump. Three types of needles of the same manufacturer (Pajunk) and same diameter (22G) but with different tips (Facet, Facet S and Sprotte) were used to measure injection pressures during penetration through tissues until interfascial plane hydrodissection was created. Statistical analyses were performed to compare pressure levels, variability, and temporal pressure trends. Results: Ninety ultrasound guided injections in porcine thigh tissue were analyzed, with thirty procedures per needle type. Injection pressure differed significantly between intramuscular, fascial puncture, and interfascial phases, showing a distinct puncture peak (p ≤ 3.44 × 10⁻¹⁴). Needle geometry significantly affected pressures across all phases (Kruskal–Wallis intramuscular p = 2.0 × 10⁻⁶, puncture p = 7.52 × 10⁻⁸, interfascial p = 9.2 × 10⁻⁵), with large pairwise effects (Hedges g up to 1.51). The classical tip produced the highest intramuscular and higher interfascial pressures, the sharp tip required the lowest puncture pressure, and the lateral tip yielded the lowest intramuscular and interfascial pressures. Conclusions: Needle tip geometry substantially influences pressure dynamics throughout the injection process, with the classical design associated with the highest fascia-penetration injection pressures and the sharp needle exhibiting the lowest, while the lateral design associated with lowest intramuscular-penetration and interfascial pressures. 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: Targeted muscle reinnervation (TMR) is increasingly used to enhance prosthetic control and to reduce post-amputation pain. Its implementation across new centers raises questions about the reproducibility of outcomes and the impact of surgical experience. Methods: We compared the first three TMR patients treated in a newly established center in Nantes, France, with three patients treated in a high-volume center in Göttingen, Germany. Functional outcomes were measured using the Box and Block test (BBT), and operative time was recorded. Two French cases were performed with the assistance of a Göttingen-based surgeon. Conclusions: The functional outcomes showed a similar trend in both groups. The mean BBT scores were equivalent, suggesting reliable reinnervation and prosthetic integration even in early cases. Operative times were longer in Nantes, but did not impact outcomes. TMR appears not to have a pronounced learning curve, particularly regarding functional success in early cases under guided protocols. Factors such as assistance from experienced surgeons and favorable donor-to-recipient nerve ratios likely contribute to consistent outcomes. These findings support the reproducibility of TMR across institutions. Results: Within the first two years of rehabilitation we observed improvements in both functional performance and patient-reported quality of life. All six patients across both centers in-creased in BBT scores. All the patients reported an increase in social relationships and psychological health, and two of three patients reported an increase in physical health. Importantly, all six patients discontinued the use of pain medication at 2 years fol-lowing TMR. Furthermore, the French patients reported a decrease from 65–82 mm to 0–31 mm across the patients’ Visual Analog Scale (VAS) pain scores. Full article

Background: Mounting evidence suggests that medical management may differ significantly between female and male patients. Despite studies showing increased sensitivity to pain, female patients receive less opioid analgesia compared to male patients after surgery. It is uncertain whether perioperative multimodal analgesia differs between sexes in thoracic surgery. Methods: A retrospective cohort study from January to July 2023 comparing multimodal analgesia and perceived pain in the early postoperative period between female and male patients after video-assisted thoracic surgery (VATS). The primary endpoint was the opioid demand in the post-anaesthesia care unit (PACU). Secondary outcomes included pain scores, regional anaesthesia and pain therapy by female, male or mixed teams. Results: Overall, 46.0% (n = 92) of the 200 included patients were female and 54% (n = 108) were male. Following VATS, the median piritramide demand was 9.0 [5.3 to 14.9] mg in female vs. 7.7 [4.5 to 12.9] mg in male patients (p = 0.35). Pain scores and regional anaesthesia were comparable between groups. In the early postoperative period, more opioids were administered overall and to female patients by all female anaesthesia teams, compared to mixed or all-male teams. Conclusions: The weight-adjusted dose of postoperative opioids did not differ between groups; neither did postoperative pain scores or the application of nerve blocks. The increased opioid demand in female patients was met by all female teams but not by all-male or mixed teams. Full article

Background/Objectives: Fluoroscopically guided cervical nerve root corticosteroid injections are used for the treatment and diagnosis of radicular pain. Including a local anesthetic with the injected corticosteroid may decrease the pain associated with the procedure and add immediate diagnostic value. However, little is known about the safety of including a local anesthetic with a corticosteroid in these injections. Methods: A total of 299 consecutive cervical nerve root injections, performed between 2016 and 2024, were reviewed. Demographic and injection information (level/laterality and inclusion/exclusion of 1% preservative-free lidocaine with dexamethasone injectate) were documented. Charts were reviewed for major complications and increased pain post-procedure. Categorical data were compared between groups using Fisher’s exact test or Chi-square testing. Results: Injections were performed with 10 mg of dexamethasone only in 263 cases and with a mixture of 10 mg of dexamethasone and 1 mL of 1% lidocaine in 36 cases. There was no statistically significant difference in the incidence of major complications (p ≈ 1) or immediately increased pain post-procedure (p = 0.799). Conclusions: With proper technique, there is no evidence from this case–control study or in the available literature to suggest that including lidocaine with corticosteroid increases risks associated with cervical nerve root injections. However, serious adverse events are theoretically possible with injection of local anesthetic into a radicular artery, the vertebral artery, or subdural space. Given that such risks are not associated with the use of non-particulate steroids alone, large multi-institutional studies are needed to draw confident conclusions on the risks and benefits of the inclusion of local anesthetics with non-particulate corticosteroids for cervical transforaminal epidural steroid injection to inform clinical practice. Full article

Background: Burning Mouth Syndrome (BMS) is a chronic orofacial pain condition characterized by a burning sensation in the oral cavity without identifiable lesions. It predominantly affects women (especially postmenopausal) but can occur in men. BMS is considered a multifactorial neuropathic pain disorder involving both peripheral small-fiber neuropathy and central dysregulation, often accompanied by taste alterations (dysgusia) and xerostomia despite normal oral exams. Treatment is challenging, with modest responses to agents like clonazepam, tricyclic antidepressants, or gabapentinoids. Observations: We present a 67-year-old male with recalcitrant primary BMS who showed complete remission temporally associated with occipital nerve blockade, likely affecting central trigeminocervical pathways. Initial therapy with amitriptyline (25 mg) and gabapentin (900 mg/day) yielded ~30% pain relief. Given suspected central sensitization, greater and lesser occipital nerve (GON) blocks were administered in series. After the first, second, and third ON blocks, pain was reduced by ~50%, 80%, and 100%, respectively. Remission persisted at one-year follow-up under continued medications. A mild recurrence (~20% of baseline pain) responded fully to a fourth GON block, maintaining another year of pain-free status. Lessons: This case underscores the complex central mechanisms in BMS and illustrates that modulating central pain circuits via occipital nerve blockade, through trigeminocervical convergence mechanisms, without direct trigeminal intervention. We discuss the diagnostic challenges of BMS, the rationale of occipital neuromodulation, and how this novel therapeutic strategy compares with current literature, supporting the hypothesis of central sensitization in BMS. Full article

Mandibular dental disease is common in pet rabbits and often requires invasive procedures associated with significant nociceptive input. Mandibular alveolar nerve blocks have been described in this species using blind techniques; however, their accuracy has not been objectively evaluated, and ultrasound-guided approaches have not been reported. This cadaveric study aimed to describe an ultrasound-guided mandibular alveolar nerve block in rabbits and to compare in-plane and out-of-plane approaches. Twelve adult New Zealand White rabbit cadavers (24 mandibular alveolar nerves) were included. For each rabbit, one nerve was assigned to an in-plane ultrasound-guided approach, while the contralateral nerve was assigned to an out-of-plane approach. Following ultrasound-guided needle placement, 0.1 mL/kg of a mixture of 2% lidocaine and 1% methylene blue was injected. Ultrasound image quality and perineural staining were assessed and scored, and longitudinal dye spread was measured after anatomical dissection. Both approaches allowed consistent identification of the target region and resulted in comparable ultrasound image quality scores, staining scores, and longitudinal dye spread, with no statistically significant differences between techniques. These results demonstrate the anatomical feasibility of ultrasound-guided mandibular alveolar nerve blocks in rabbits using either approach. Further in vivo studies are required to assess clinical efficacy and safety. Full article

Background: Stroke is a leading cause of long-term disability worldwide. Non-invasive or transcutaneous auricular vagus nerve stimulation (taVNS) shows promise in promoting neuroplasticity and supporting motor recovery. There are currently no validated biomarkers of taVNS. High-density diffuse optical tomography (HD-DOT) is a portable neuroimaging technology that uses near-infrared light to map cortical activity via the quantification of changes in blood oxygenation. The aim of this study was to determine whether HD-DOT could detect motor task-related activity with concurrent taVNS. Methods: Thirty-one healthy participants completed right and left finger tapping tasks with concurrent sham (earlobe) and then active (tragus) taVNS in a within-subject block design. HD-DOT was recorded across the bilateral sensorimotor cortex using 36 sources and 48 detectors (1728 channels). Cortical reconstructions were parcellated and block-averaged task-related oxygenated and deoxygenated haemoglobin changes were compared between sham and active taVNS conditions. Results: In a group-level analysis, appropriate lateralised task-related haemodynamic responses were seen in the contralateral sensorimotor regions, demonstrating the validity of HD-DOT. Between-group comparisons showed no significant change in task-related activation during right finger tapping tasks under active vs. sham taVNS conditions. A non-significant redistribution of task-related activity to the right motor cortex was seen with left finger tapping under active taVNS compared to sham taVNS. Conclusions: Simultaneous recording of neural responses to taVNS during motor activity was feasible and well tolerated. Reliable task-related activation was recordable. Future studies of whole brain HD-DOT in people with stroke will help evaluate its potential as a biomarker in taVNS. Full article

This study developed a virtual reality (VR) simulator for training the inferior alveolar nerve block (IANB) procedure using Leap Motion-based hand tracking and the Unity engine, and evaluated its interaction performance, task-level outcomes within the simulator, and usability. Built on a 3D anatomical model, the system provides a pre-clinical practice environment for realistic syringe manipulation and visually guided needle insertion, enabling repeated rehearsal of the procedural workflow. Interaction stability was assessed using participant-level gesture recognition rates and input latency. Usability was evaluated via a questionnaire addressing ease of use, cognitive load, and perceived educational usefulness. The results indicated participant-level mean gesture recognition rates of 88.8–90.5% and mean response latencies of approximately 64–66 ms. In usability testing (n = 40), the item related to perceived procedural skill improvement received the highest score (4.25/5.0). Because this study did not include controlled comparisons with conventional training or objective measures of clinical competency transfer, the findings should be interpreted as preliminary evidence of technical feasibility and learner-perceived usefulness within a simulated setting. Controlled comparative studies using objective learning outcomes are warranted. Full article