Advancements in the medical field with regard to the development of new techniques, reassessment and analyses of the old and unsatisfactory techniques and the expansion and improvement of acceptable techniques have led to an increase in the use of regional anaesthetic nerve blocks in paediatric patients. However, several regional anaesthetic procedures are currently not being performed by anaesthetists due to the high number of complications and difficulties experienced. Some medical practitioners are under the impression that they lack the knowledge and confidence to perform these regional nerve blocks, especially on neonatal and infant patients. In order to assist these doctors in refining their anatomical knowledge and increasing their confidence in performing these nerve blocks, the procedures which are experienced as problematic need to be identified and evaluated. The aim of this study was therefore: (1) to establish the most efficient method of blocking the maxillary nerve within the pterygopalatine fossa; (2) to investigate which head and neck regional nerve blocks are performed most frequently on paediatric patients and identify problem procedures that are performed by practicing anaesthesiologist in South Africa; (3) to develop a clinical anatomy information base for the selected procedures. Three methods / techniques for maxillary nerve blocks were simulated and compared on 24 dry paediatric skulls and 30 dissected paediatric cadavers. The depth and angles at which the needle travels to block the maxillary nerve in the pterygopalatine fossa, after existing the skull through the foramen rotundum, was measured and compared. The method using the supra-zygomatic approach (method B), from the frontozygomatic angle towards the pterygopalatine fossa, exhibited no statistical significance (p > 0.05) when comparing the measurements in the skulls and cadavers. Method A, a supra-zygomatic approach from the midpoint on the lateral border of the orbit, as well as method C, an infra-zygomatic approach with an entry at the site of a vertical line extending along the lateral orbit wall, showed statistical significance when comparing measurements in the skulls and cadavers. It can therefore be concluded that method B produces the most consistent data and should be tested in a clinical setting. Seventeen commonly performed paediatric regional nerve blocks were identified. A detailed questionnaire was completed by 111 respondents, either electronically or from others attending either the Pain Interventions and Regional Anaesthesia Conference or the South African Society of Anaesthesiologists Conference. Difficulties in performing the regional anaesthetic nerve blocks, and complications encountered, were the main areas of focus, when selecting the four problem procedures. The problem procedures selected are the following: supra-orbital and supra-trochlear nerve blocks, infra-orbital nerve block (Extra-oral approach), superior laryngeal and recurrent laryngeal nerve blocks. A detailed anatomical information base was developed through an extensive literature review. This will aid in educating and facilitating doctors in performing paediatric regional nerve blocks, thereby enabling them to successfully practice medicine. / Dissertation (MSc)--University of Pretoria, 2013. / gm2014 / Anatomy / unrestricted

BACKGROUND: Hip preservations surgeries are a type of surgical intervention used to often delay or prevent arthritis in patients before damage has occurred. A hip arthroscopy, a type of hip preservation surgery, allows for a minimally invasive method by using an arthroscope, a small fiber-optic tube with a camera attached, and surgical tools to perform the surgery. Hip preservation surgeries are often linked with moderate to severe postoperative pain, often leading to the use of substantial anesthesia. Nerve blocks have become increasingly popular for certain procedures as there may be advantages with postoperative pain and other same-day recovery advantages. Nerve blocks continue to be investigated in their role in lowering postoperative pain, postoperative opioid consumption, length of stay/time in postoperative anesthesia care unit, and patient satisfaction of pain control. OBJECTIVE: The objective of this systematic review was to determine the efficacy of nerve blocks for postoperative pain management in hip arthroscopies. METHODS: Two reviewers (J.A., E.B.) independently conducted a literature search in January 2022 with adjudication by a third reviewer using the databases Pubmed, EMBASE, and Medline. The included studies were systematically screened and reviewed, and data was analyzed. RESULTS: With a quadratus lumborum block, a study showed a significant difference in postoperative VAS pain scores in the study group with a block compared to the control from admission into the PACU through 24 hours after the operation (P<.001). In postoperative opioid consumption, another significant difference was reported in the group with a lumbar plexus block compared to control from the PACU all the way to 24 hours post operation (P<.001). When comparing a fascia iliaca block versus a local infiltration analgesia, a study found that 1 hour post operation the patients reported a significantly lower mean pain level. However, it was found that a fascia iliaca block may be less effective in reducing the number of opioids consumed in the PACU compared to a lumbar plexus block (P=.020). With a femoral nerve block, reports show a significant reduction in postoperative pain using VAS at 30 minutes (P=.009), 1 hour (P=.004), 2 hours(P=.003), 4 hours(P=.006) and 6 hours (P=.0002). Patients who receive a femoral nerve block consumed a mean amount of 47.6 milligrams of morphine equivalents compared to 59.2 milligrams of morphine equivalents in the control group which is significantly less (P=.006). Patients with a lumbar plexus block reported a lower mean pain score compared to a combined spinal epidural (P=.048) at 48 hours (YaDeau et al., 2012). There was no difference observed in pain scores when a lumbar plexus block was compared to a pericapsular injection. The lumbar plexus block had no differences in opioid consumption when compared to both combined spinal epidural and pericapsular injection. CONCLUSION: The use of nerve blocks provides sufficient pain management in hip arthroscopies. The effectiveness of these blocks may be more than other types of analgesic methods in lowering postoperative pain and postoperative opioid consumption.

Interscalene nerve blocks are common procedures performed before upper extremity surgeries in order to provide post-op pain relief and improve recovery time. Here we present two cases of patients who underwent a unilateral supraclavicular and bilateral interscalene nerve block, respectively. The first patient had no risk factors but the second presented with a body mass index of 45.5 and a history of symptoms consistent with obstructive sleep apnea but never diagnosed. Both patients experienced some form of respiratory distress diagnosed via changes in chest x-ray and clinical presentation. The mechanism of injury that occurs in these procedures is typically from inadvertent damage to the phrenic nerve. Mild adverse effects in interscalene nerve block are relatively common. However, there is minimal data in regards to performing bilateral interscalene nerve blocks. The purpose of this study is to highlight that severe complication in both high and low-risk patients can occur but may be reduced with a safer approach and more effective communication among multidisciplinary team members.

The primary focus of this thesis is to establish the clinical utility of corticosteroid injections mixed with local anesthetics, when compared to only local anesthetics, for relief of pain in patients with chronic non-cancer pain. Chronic non-cancer pain is common and causes significant pain and suffering to patients, and economic burden to health care system. Injection of steroids is an option, either by targeting the painful structure or the associated neural elements. Steroids are commonly mixed with local anesthetics in the hope of prolonging the pain relief. Since there is no evident inflammation in most chronic pain conditions, and because existing clinical studies do not consistently support its effectiveness in various clinical conditions, the potential value of adding steroids is questionable. This clinical question has been addressed through a comprehensive systematic review and meta-analysis of randomized control trials comparing injections of steroid with local anesthetics against only local anesthetics for chronic non-cancer pain conditions. Our review found that there is paucity of good quality randomized controlled studies specifically addressing this comparison. Although a large numbers of studies were identified, there was a small effect favoring steroids in studies measuring pain relief by dichotomous outcomes. Overall confidence in the effect estimates were limited due to serious concerns of bias, significant heterogeneity and variability in studies, leading to low quality. A majority of the included studies did not aim to capture the full spectrum of adverse effects. Future studies addressing this clinical question should aim to be of optimum size, must aim to limit the threat of bias, and capture all patient important outcomes including pain relief. / Thesis / Master of Science (MSc)

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Background: Current recommended treatment options for primary headache disorders are suboptimal in that effective pain relief is untimely and associated with side effects. Objective: The primary aim of this thesis was to evaluate the effectiveness and attitudes towards an alternative treatment option, the sphenopalatine ganglion (SPG) block which belongs to a class of procedures known as peripheral nerve blocks (PNBs). Methods: We conducted a systematic review and meta-analysis studying the effectiveness of PNBs for the treatment of primary headache disorders. We also conducted a national postal survey among Canadian emergency physicians to identify current practice patterns and perspectives on PNBs. Results: We found PNBs are effective for rapid pain relief compared to placebo at 15 minutes (MD = -1.17; 95% CI: -1.82 to -0.51) and 30 minutes (MD = -0.99; 95% CI: -1.66 to -0.32). Only 55.6% of physicians have experience with PNBs (95% CI: 0.48 to 0.65) and we discovered the SPG block is the least commonly practiced type of PNB; the majority of physicians believe these procedures are safe (85%) and effective (55.1%). A future trial is needed to compare the SPG block against standard treatment. Conclusion: The SPG block may be used as an adjunct therapy for faster effective pain relief. Current physicians would consider PNBs as a first-line alternative given evidence from a future trial. A future trial is needed to compare the SPG block against standard treatment.