Ahmed Thallaj

Introduction: Injury to the medial brachial and the medial antebrachial nerves may occur after brachioplasty and may lead to severe pain. We report on two cases to demonstrate that high-resolution ultrasound may be used as an aid in the diagnosis and treatment of post-brachioplasty injury to these small cutaneous nerves. Case reports: We report on two cases. The first case was a 29-year old female with severe arm pain secondary to a neuroma of the right medial brachial nerve. The diagnosis of a neuroma was done using high-resolution ultrasound and proximal nerve block led to immediate complete relief of pain. Recurrent but milder pain occurred and this was treated with multiple nerve blocks. The second case was a 34-year-old female with severe arm/forearm pain secondary to entrapment of the left medial antebrachial cutaneous nerve by a suture in the middle arm. The diagnosis was reached using high-resolution ultrasound and proximal nerve block led to immediate complete relieve of pain. Recurrent but milder pain occurred and this was treated by surgical nerve decompression. Discussion: Previous literature confirms that high-resolution ultrasound can accurately identify small sensory nerves of the arm and forearm. Conclusion: We demonstrate that high resolution ultrasound may be used as an aid in the diagnosis and treatment of post-brachioplasty injury to the medial brachial and the medial antebrachial nerves. Proximal nerve block is extremely effective to relief the severe pain in these patients. However, recurrence of pain is expected and further management may be done by a trial of repeated injections or by surgical exploration. Highlights:

Total hip arthroplasty (THA) is considered an extremely painful procedure. Postoperative analgesic technique especially in an elderly with significant comorbidities is even more challenging. Pericapsular nerve group (PENG) block is a novel technique that has been described recently as an effective analgesic method for hip surgery. We report a case of a successful PENG and lateral femoral cutaneous nerve blocks for postoperative analgesia in THA.

Triceps nerve-to-deltoid nerve transfer requires the identification of the axillary nerve in the quadrilateral space. This may be difficult especially for residents-in-training. The senior author is a Professor of Hand Surgery at a teaching institution and has devised a new technique of identification of the axillary nerve and its cutaneous branch using surface land-marks and on-table ultrasonography. The axillary nerve and the quadrilateral space is first identified using anatomical landmarks. The ultrasound probe is the used to identify the quadrilateral space and the axillary nerve which appears as hyper-echoic oval-shaped structure. The ultrasound probe is then moved to scan the cutaneous branch of the axillary nerve as it branches-off the main nerve trunk. Finally, the cutaneous branch is traced superficially till it becomes subcutaneous. This point is marked and the skin incision is made along this marked point. During surgery, the cutaneous branch is followed retrograde to the axillary nerve in the quadrilateral space. Ultrasound guidance for localization of various nerves is now routinely done by anesthetists in the Operating Room. This localization is used for nerve blocks and in patients with brachial plexus injuries. Hence, the ultrasound machine and the expertise are already available in the operating room; and no special arrangements with the Radiology Department are needed. A technique of identification of the cutaneous branch of the axillary nerve using anatomical landmarks and ultrasonography is described. The localization is accurate and is of help in patients undergoing triceps nerve-to-deltoid nerve transfer.

We report here the management of glass fragment buried in the soft tissue close to the ulnar nerve. Also discuss how ultrasound provides real-time guidance without radiation exposure and emphasize the importance of this evolving and exciting imaging field.

In the past nerve stimulation was considered the standard tool for anesthesiologists to locate the peripheral nerve for nerve blocks. However, with the recent introduction of ultrasound (US) technology for regional anesthesia, the use of nerve stimulation has become a rarity nowadays. There is a growing interest by most anesthesiologists in using US for nerve blocks because of its simplicity and accuracy. US is now available in most hospitals practicing regional anesthesia and is a popular tool for performance of nerve blocks. Although nerve stimulation became a rarity, however the use of it is now limited to identify small nerve structures, such as greater auricular nerve and medial antebrachial cutaneous nerve of the forearm. However, in this review article we discuss the role of ultrasonography for greater auricular and antebrachial cutaneous nerve blocks, which could replace nerve stimulation technique. We look at the available literature on the role of US for the performance of uncommon nerve blocks and its benefits.

Background: During transurethral resection surgery (TUR), accidental stimulation of the obturator nerve can cause violent adductor contraction, leading to serious intraoperative complications. General anesthesia with muscle relaxation is currently the preferred technique for TUR surgery. Spinal anesthesia combined with obturator nerve block has also been used for TUR surgery in geriatric population. Blind, anatomical methods for identifying the obturator nerve are often unsatisfactory. Therefore, we conducted this prospective study to validate the efficacy of ultrasound-guided obturator nerve block (USONB) during TUR procedures. Methods: Eighteen male patients undergoing TURP surgery under spinal anesthesia were included in the study. Bilateral USONB with maximum 20 ml of 1% lidocaine per patient was performed. An independent observer was present to monitor any adduction movements during the operation and to record patient and surgeon satisfactions. Results: In all patients, obturator nerve was visualized from the first attempt, requiring an average of 4.3 min for blocking of each side. USONB was successful (97.2%) in preventing an adductor spasm in all except one patient. Patient's and surgeon's satisfaction were appropriate. In all patients, adductor muscle strength recovered fully within 2 h following the surgical procedure. Conclusions: USONB is safe and effective during TUR surgery. It provides optimal intra-and postoperative conditions.