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Diagnostic nerve block in prediction of outcome of botulinum toxin treatment for spastic equinovarus foot after stroke: A retrospective observational study.

诊断性神经阻滞预测中风后痉挛性马蹄内翻足的肉毒毒素治疗结果: 一项回顾性观察研究。

  • 影响因子:2.17
  • DOI:10.2340/16501977-2693
  • 作者列表:"Picelli A","Battistuzzi E","Filippetti M","Modenese A","Gandolfi M","Munari D","Smania N
  • 发表时间:2020-06-12
Abstract

OBJECTIVE:To evaluate the role of diagnostic nerve block in predicting the outcome of subsequent botulinum toxin type A treatment for spastic equinovarus foot due to chronic stroke. DESIGN:Retrospective observational study. PATIENTS:Fifty chronic stroke patients with spastic equinovarus foot. METHODS:Each patient was given diagnostic tibial nerve block (lidocaine 2% perineural injection) assessment followed by botulinum toxin type A inoculation into the same muscles as had been targeted by the nerve block. All patients were evaluated before diagnostic nerve block, after the nerve block, and 4 weeks after botulinum toxin injection. Outcomes were ankle dorsiflexion passive range of motion of the affected side, and calf muscle spasticity, measured with the modified Ashworth scale and the Tardieu Scale. RESULTS:Significant improvements were measured after diagnostic nerve block and botulinum toxin injection compared with the baseline condition. Diagnostic nerve block led to significantly greater improvements in all outcomes than botulinum toxin injection. CONCLUSION:This study confirmed diagnostic nerve block as a valuable screening tool in deciding whether to treat spastic equinovarus with botulinum toxin. However, the results support the evidence that diagnostic nerve block results in a greater reduction in muscle overactivity than does botulinum toxin type A in patients with spastic equinovarus due to stroke.

摘要

目的: 评价诊断性神经阻滞在预测后续a型肉毒毒素治疗慢性卒中所致痉挛性马蹄内翻足的疗效中的作用。 设计: 回顾性观察研究。 患者: 50例痉挛型马蹄内翻足的慢性脑卒中患者。 方法: 对每位患者进行诊断性胫神经阻滞 (利多卡因2% 神经周围注射) 评估,然后将a型肉毒毒素接种到神经阻滞靶向的相同肌肉中。所有患者均在诊断性神经阻滞前、神经阻滞后、肉毒毒素注射后4周进行评估。结果是患侧踝关节背屈被动活动度和小腿肌肉痉挛,用改良Ashworth量表和Tardieu量表测量。 结果: 在诊断性神经阻滞和肉毒杆菌毒素注射后,与基线条件相比,测量到显著改善。与肉毒杆菌毒素注射相比,诊断性神经阻滞导致所有结果的显著改善。 结论: 本研究证实诊断性神经阻滞是决定是否用肉毒杆菌毒素治疗痉挛性马蹄内翻足的有价值的筛选工具。然而,该结果支持了以下证据: 与a型肉毒杆菌毒素相比,由于中风导致的痉挛性马蹄内翻足患者的诊断性神经阻滞导致肌肉过度活动的更大减少。

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发表时间:2020-01-01
DOI:10.1213/ANE.0000000000003975
作者列表:["Uppal V","Retter S","Casey M","Sancheti S","Matheson K","McKeen DM"]

METHODS:BACKGROUND:Fentanyl and morphine are the 2 most commonly added opioids to bupivacaine for spinal anesthesia during cesarean delivery. Numerous clinical trials have assessed efficacy and safety of different doses of fentanyl added to intrathecal bupivacaine for spinal anesthesia, yet its benefit, harm, and optimal dose remain unclear. This study aimed to systematically review the evidence of the efficacy of fentanyl when added to intrathecal bupivacaine alone and when added to bupivacaine with morphine for spinal anesthesia during cesarean delivery. METHODS:Key electronic databases (PubMed, Embase, and Cochrane Library) were searched for randomized controlled trials in the cesarean delivery population. The primary outcome was the failure rate of spinal anesthesia, as assessed by the need for either conversion to general anesthesia or intraoperative analgesic supplementation. Two reviewers independently extracted the data using a standardized electronic form. Results are expressed as relative risks or mean differences with 95% CIs. RESULTS:Seventeen randomized controlled clinical trials (most judged as low or unclear risk of bias) with 1064 participants provided data for the meta-analysis. Fentanyl added to intrathecal bupivacaine alone reduced the need for intraoperative supplemental analgesia (relative risk, 0.18; 95% CI, 0.11-0.27; number needed to treat, 4) and the incidence of nausea/vomiting (relative risk, 0.41; 95% CI, 0.24-0.70; number needed to treat, 6.5), with longer time to first postoperative analgesia request (mean difference, 91 minutes; 95% CI, 69-113). No difference was observed regarding the need for conversion to general anesthesia (relative risk, 0.67; 95% CI, 0.12-3.57), the incidence of hypotension, the onset of sensory block, or the duration of motor block. However, the addition of intrathecal fentanyl was associated with higher incidence of intraoperative pruritus (relative risk, 5.89; 95% CI, 2.07-16.79; number needed to harm, 13.5). The inclusion of fentanyl to intrathecal bupivacaine-morphine compared to intrathecal bupivacaine-morphine alone conferred a similar benefit, with a significantly reduced need for intraoperative supplemental analgesia (relative risk, 0.16; 95% CI, 0.03-0.95; number needed to treat, 9). Analysis using a funnel plot indicated a possibility of publication bias in included studies. CONCLUSIONS:Current evidence suggests a benefit of using fentanyl as both an additive to intrathecal bupivacaine alone and to intrathecal bupivacaine combined with morphine for cesarean delivery under spinal anesthesia. The possibility of publication bias, small sample size, and high risk of bias in some of the included studies warrant treating the results with caution.

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影响因子:2.27
发表时间:2020-05-01
DOI:10.1213/ANE.0000000000004012
作者列表:["Jean YK","Kam D","Gayer S","Palte HD","Stein ALS"]

METHODS::Ophthalmic pediatric regional anesthesia has been widely described, but infrequently used. This review summarizes the available evidence supporting the use of conduction anesthesia in pediatric ophthalmic surgery. Key anatomic differences in axial length, intraocular pressure, and available orbital space between young children and adults impact conduct of ophthalmic regional anesthesia. The eye is near adult size at birth and completes its growth rapidly while the orbit does not. This results in significantly diminished extraocular orbital volumes for local anesthetic deposition. Needle-based blocks are categorized by relation of the needle to the extraocular muscle cone (ie, intraconal or extraconal) and in the cannula-based block, by description of the potential space deep to the Tenon capsule. In children, blocks are placed after induction of anesthesia by a pediatric anesthesiologist or ophthalmologist, via anatomic landmarks or under ultrasonography. Ocular conduction anesthesia confers several advantages for eye surgery including analgesia, akinesia, ablation of the oculocardiac reflex, and reduction of postoperative nausea and vomiting. Short (16 mm), blunt-tip needles are preferred because of altered globe-to-orbit ratios in children. Soft-tip cannulae of varying length have been demonstrated as safe in sub-Tenon blockade. Ultrasound technology facilitates direct, real-time visualization of needle position and local anesthetic spread and reduces inadvertent intraconal needle placement. The developing eye is vulnerable to thermal and mechanical insults, so ocular-rated transducers are mandated. The adjuvant hyaluronidase improves ocular akinesia, decreases local anesthetic dosage requirements, and improves initial block success; meanwhile, dexmedetomidine increases local anesthetic potency and prolongs duration of analgesia without an increase in adverse events. Intraconal blockade is a relative contraindication in neonates and infants, retinoblastoma surgery, and in the presence of posterior staphylomas and buphthalmos. Specific considerations include pertinent pediatric ophthalmologic topics, block placement in the syndromic child, and potential adverse effects associated with each technique. Recommendations based on our experience at a busy academic ophthalmologic tertiary referral center are provided.

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