The document discusses several new and emerging concepts in nerve blocks. It covers new equipment like echogenic needles and catheters, ultrasonography advances like 3D and 4D ultrasound, and pressure monitoring devices. It also discusses learning tools like phantoms and robots. Newer nerve blocks described include the erector spinae block and rhomboid block. Adjuvants to prolong peripheral nerve blocks and new formulations like liposomal bupivacaine and proliposomal ropivacaine are covered.
new technique for pain management ,described by dr forero ,it can replace epidural anesthesia,paravertebral anesthesia and other regional blocks.it can be used for both acute and chronic painful conditions
Erector spinae plane block is a relatively novel approach to pain management for a variety of surgical procedures. ESP block is a challenging anesthesia and analgesia technique that needs more research.
new technique for pain management ,described by dr forero ,it can replace epidural anesthesia,paravertebral anesthesia and other regional blocks.it can be used for both acute and chronic painful conditions
Erector spinae plane block is a relatively novel approach to pain management for a variety of surgical procedures. ESP block is a challenging anesthesia and analgesia technique that needs more research.
Regional Blocks of the Upper Limb and Thorax RRTRanjith Thampi
Blocks of the UL and Thorax made easy. Most methods mentioned here are modifications and not classical methods used that maybe be required for examination writing purpose.
Pre-oxygenation is: safe, simple, cheap, effective, well-tolerated. This article provides a compelling argument in favour of pre-oxygenation prior to all general anaesthesia.
Regional Blocks of the Upper Limb and Thorax RRTRanjith Thampi
Blocks of the UL and Thorax made easy. Most methods mentioned here are modifications and not classical methods used that maybe be required for examination writing purpose.
Pre-oxygenation is: safe, simple, cheap, effective, well-tolerated. This article provides a compelling argument in favour of pre-oxygenation prior to all general anaesthesia.
There are currently few options to extend the duration of regional analgesia at home beyond the one day expected from most single-injection nerve blocks. Continuous peripheral nerve block (CPNB) with a plain local anesthetic perineural infusion is the most established way to provide days of postoperative pain control and allows titration, but training in insertion techniques and a system to manage ambulatory CPNB patients are necessary. Adjuvants or depot formulations of local anesthetics may offer potential options for limited extension of block duration, but further studies regarding efficacy and safety for regional anesthesia as well as comparative-effectiveness versus CPNB are necessary.
At the conclusion of this activity, learners will be able to: discuss the indications for continuous peripheral nerve blocks; identify obstacles to implementing a continuous peripheral nerve block system; examine various techniques and equipment for continuous peripheral nerve block performance; and discuss the application of ultrasound guidance for perineural catheter insertion.
At the conclusion of this activity, learners will be able to: discuss the benefits of regional anesthesia on pain and rehabilitative outcomes; identify applications of “big data” in outcomes assessment; and critically evaluate the evidence related to regional anesthesia and analgesia and long-term outcomes.
Effectiveness and safety of CPNB and continuous local wound infusion
Basal infusion with PCA option
Types of pumps – elastomeric vs. electronic
Outpatient and home infusion pumps
At the conclusion of the activity participants should be able to: discuss the value-based purchasing program and its components; identify aspects of the HCAHPS survey that directly and indirectly relate to inpatient pain management; and apply strategies to provide high quality pain management and minimize risks for postsurgical patients.
After completion of this session, students should be able to discuss, identify, and describe:
The anatomical factors predisposing to nerve injuries.
The anatomy of deformity, weakness and sensory loss following the nerve injury.
The applied anatomy of clinical examination for specific nerves.
Surgical anatomy of treating nerve injuries.
After completion of this session, students should be able to discuss, identify, and describe:
The anatomical factors predisposing to nerve injuries.
The anatomy of deformity, weakness and sensory loss following the nerve injury.
The applied anatomy of clinical examination for specific nerves.
Surgical anatomy of treating nerve injuries.
Field of pharmacology
Pharmacology practice school report .
Final year b pharmcy
Domain-Pharmacology
It include
1) experimental pharmacology
2) Toxicity study
3)pharmacovigilance
Dr.Pragnesh Shah is Gynaecological Endoscopic surgeon from Ahmedabad,Gujarat,India and having keen interest in Gynaecological Endoscopic Training. He is having experience of most of the difficult and complicated laparoscopic and hysteroscopic surgeries with world class infra structure in Ahmedabad.
He has given Gynaecological Endoscopic Training to many Gynaecologists and surgeons of the world.
Recent advances toward preclinical and clinical translation of photoacoustic ...hoormohameed2019
Photoacoustic imaging is an emerging hybrid imaging modality that can provide multicontrast,
multiscale imaging of biological features ranging from organelles to organs. The three major embodiments of
photoacoustic imaging are microscopy, endoscopy, and computed tomography. Photoacoustic tomography
(PAT) or photoacoustic computed tomography allows deep-tissue imaging, and hence it is more suitable for
whole body preclinical/clinical imaging applications
Lung Cancer: Artificial Intelligence, Synergetics, Complex System Analysis, S...Oleg Kshivets
RESULTS: Overall life span (LS) was 2252.1±1742.5 days and cumulative 5-year survival (5YS) reached 73.2%, 10 years – 64.8%, 20 years – 42.5%. 513 LCP lived more than 5 years (LS=3124.6±1525.6 days), 148 LCP – more than 10 years (LS=5054.4±1504.1 days).199 LCP died because of LC (LS=562.7±374.5 days). 5YS of LCP after bi/lobectomies was significantly superior in comparison with LCP after pneumonectomies (78.1% vs.63.7%, P=0.00001 by log-rank test). AT significantly improved 5YS (66.3% vs. 34.8%) (P=0.00000 by log-rank test) only for LCP with N1-2. Cox modeling displayed that 5YS of LCP significantly depended on: phase transition (PT) early-invasive LC in terms of synergetics, PT N0—N12, cell ratio factors (ratio between cancer cells- CC and blood cells subpopulations), G1-3, histology, glucose, AT, blood cell circuit, prothrombin index, heparin tolerance, recalcification time (P=0.000-0.038). Neural networks, genetic algorithm selection and bootstrap simulation revealed relationships between 5YS and PT early-invasive LC (rank=1), PT N0—N12 (rank=2), thrombocytes/CC (3), erythrocytes/CC (4), eosinophils/CC (5), healthy cells/CC (6), lymphocytes/CC (7), segmented neutrophils/CC (8), stick neutrophils/CC (9), monocytes/CC (10); leucocytes/CC (11). Correct prediction of 5YS was 100% by neural networks computing (area under ROC curve=1.0; error=0.0).
CONCLUSIONS: 5YS of LCP after radical procedures significantly depended on: 1) PT early-invasive cancer; 2) PT N0--N12; 3) cell ratio factors; 4) blood cell circuit; 5) biochemical factors; 6) hemostasis system; 7) AT; 8) LC characteristics; 9) LC cell dynamics; 10) surgery type: lobectomy/pneumonectomy; 11) anthropometric data. Optimal diagnosis and treatment strategies for LC are: 1) screening and early detection of LC; 2) availability of experienced thoracic surgeons because of complexity of radical procedures; 3) aggressive en block surgery and adequate lymph node dissection for completeness; 4) precise prediction; 5) adjuvant chemoimmunoradiotherapy for LCP with unfavorable prognosis.
Title: Sense of Smell
Presenter: Dr. Faiza, Assistant Professor of Physiology
Qualifications:
MBBS (Best Graduate, AIMC Lahore)
FCPS Physiology
ICMT, CHPE, DHPE (STMU)
MPH (GC University, Faisalabad)
MBA (Virtual University of Pakistan)
Learning Objectives:
Describe the primary categories of smells and the concept of odor blindness.
Explain the structure and location of the olfactory membrane and mucosa, including the types and roles of cells involved in olfaction.
Describe the pathway and mechanisms of olfactory signal transmission from the olfactory receptors to the brain.
Illustrate the biochemical cascade triggered by odorant binding to olfactory receptors, including the role of G-proteins and second messengers in generating an action potential.
Identify different types of olfactory disorders such as anosmia, hyposmia, hyperosmia, and dysosmia, including their potential causes.
Key Topics:
Olfactory Genes:
3% of the human genome accounts for olfactory genes.
400 genes for odorant receptors.
Olfactory Membrane:
Located in the superior part of the nasal cavity.
Medially: Folds downward along the superior septum.
Laterally: Folds over the superior turbinate and upper surface of the middle turbinate.
Total surface area: 5-10 square centimeters.
Olfactory Mucosa:
Olfactory Cells: Bipolar nerve cells derived from the CNS (100 million), with 4-25 olfactory cilia per cell.
Sustentacular Cells: Produce mucus and maintain ionic and molecular environment.
Basal Cells: Replace worn-out olfactory cells with an average lifespan of 1-2 months.
Bowman’s Gland: Secretes mucus.
Stimulation of Olfactory Cells:
Odorant dissolves in mucus and attaches to receptors on olfactory cilia.
Involves a cascade effect through G-proteins and second messengers, leading to depolarization and action potential generation in the olfactory nerve.
Quality of a Good Odorant:
Small (3-20 Carbon atoms), volatile, water-soluble, and lipid-soluble.
Facilitated by odorant-binding proteins in mucus.
Membrane Potential and Action Potential:
Resting membrane potential: -55mV.
Action potential frequency in the olfactory nerve increases with odorant strength.
Adaptation Towards the Sense of Smell:
Rapid adaptation within the first second, with further slow adaptation.
Psychological adaptation greater than receptor adaptation, involving feedback inhibition from the central nervous system.
Primary Sensations of Smell:
Camphoraceous, Musky, Floral, Pepperminty, Ethereal, Pungent, Putrid.
Odor Detection Threshold:
Examples: Hydrogen sulfide (0.0005 ppm), Methyl-mercaptan (0.002 ppm).
Some toxic substances are odorless at lethal concentrations.
Characteristics of Smell:
Odor blindness for single substances due to lack of appropriate receptor protein.
Behavioral and emotional influences of smell.
Transmission of Olfactory Signals:
From olfactory cells to glomeruli in the olfactory bulb, involving lateral inhibition.
Primitive, less old, and new olfactory systems with different path
Ethanol (CH3CH2OH), or beverage alcohol, is a two-carbon alcohol
that is rapidly distributed in the body and brain. Ethanol alters many
neurochemical systems and has rewarding and addictive properties. It
is the oldest recreational drug and likely contributes to more morbidity,
mortality, and public health costs than all illicit drugs combined. The
5th edition of the Diagnostic and Statistical Manual of Mental Disorders
(DSM-5) integrates alcohol abuse and alcohol dependence into a single
disorder called alcohol use disorder (AUD), with mild, moderate,
and severe subclassifications (American Psychiatric Association, 2013).
In the DSM-5, all types of substance abuse and dependence have been
combined into a single substance use disorder (SUD) on a continuum
from mild to severe. A diagnosis of AUD requires that at least two of
the 11 DSM-5 behaviors be present within a 12-month period (mild
AUD: 2–3 criteria; moderate AUD: 4–5 criteria; severe AUD: 6–11 criteria).
The four main behavioral effects of AUD are impaired control over
drinking, negative social consequences, risky use, and altered physiological
effects (tolerance, withdrawal). This chapter presents an overview
of the prevalence and harmful consequences of AUD in the U.S.,
the systemic nature of the disease, neurocircuitry and stages of AUD,
comorbidities, fetal alcohol spectrum disorders, genetic risk factors, and
pharmacotherapies for AUD.
Recomendações da OMS sobre cuidados maternos e neonatais para uma experiência pós-natal positiva.
Em consonância com os ODS – Objetivos do Desenvolvimento Sustentável e a Estratégia Global para a Saúde das Mulheres, Crianças e Adolescentes, e aplicando uma abordagem baseada nos direitos humanos, os esforços de cuidados pós-natais devem expandir-se para além da cobertura e da simples sobrevivência, de modo a incluir cuidados de qualidade.
Estas diretrizes visam melhorar a qualidade dos cuidados pós-natais essenciais e de rotina prestados às mulheres e aos recém-nascidos, com o objetivo final de melhorar a saúde e o bem-estar materno e neonatal.
Uma “experiência pós-natal positiva” é um resultado importante para todas as mulheres que dão à luz e para os seus recém-nascidos, estabelecendo as bases para a melhoria da saúde e do bem-estar a curto e longo prazo. Uma experiência pós-natal positiva é definida como aquela em que as mulheres, pessoas que gestam, os recém-nascidos, os casais, os pais, os cuidadores e as famílias recebem informação consistente, garantia e apoio de profissionais de saúde motivados; e onde um sistema de saúde flexível e com recursos reconheça as necessidades das mulheres e dos bebês e respeite o seu contexto cultural.
Estas diretrizes consolidadas apresentam algumas recomendações novas e já bem fundamentadas sobre cuidados pós-natais de rotina para mulheres e neonatos que recebem cuidados no pós-parto em unidades de saúde ou na comunidade, independentemente dos recursos disponíveis.
É fornecido um conjunto abrangente de recomendações para cuidados durante o período puerperal, com ênfase nos cuidados essenciais que todas as mulheres e recém-nascidos devem receber, e com a devida atenção à qualidade dos cuidados; isto é, a entrega e a experiência do cuidado recebido. Estas diretrizes atualizam e ampliam as recomendações da OMS de 2014 sobre cuidados pós-natais da mãe e do recém-nascido e complementam as atuais diretrizes da OMS sobre a gestão de complicações pós-natais.
O estabelecimento da amamentação e o manejo das principais intercorrências é contemplada.
Recomendamos muito.
Vamos discutir essas recomendações no nosso curso de pós-graduação em Aleitamento no Instituto Ciclos.
Esta publicação só está disponível em inglês até o momento.
Prof. Marcus Renato de Carvalho
www.agostodourado.com
New Drug Discovery and Development .....NEHA GUPTA
The "New Drug Discovery and Development" process involves the identification, design, testing, and manufacturing of novel pharmaceutical compounds with the aim of introducing new and improved treatments for various medical conditions. This comprehensive endeavor encompasses various stages, including target identification, preclinical studies, clinical trials, regulatory approval, and post-market surveillance. It involves multidisciplinary collaboration among scientists, researchers, clinicians, regulatory experts, and pharmaceutical companies to bring innovative therapies to market and address unmet medical needs.
Explore natural remedies for syphilis treatment in Singapore. Discover alternative therapies, herbal remedies, and lifestyle changes that may complement conventional treatments. Learn about holistic approaches to managing syphilis symptoms and supporting overall health.
NVBDCP.pptx Nation vector borne disease control programSapna Thakur
NVBDCP was launched in 2003-2004 . Vector-Borne Disease: Disease that results from an infection transmitted to humans and other animals by blood-feeding arthropods, such as mosquitoes, ticks, and fleas. Examples of vector-borne diseases include Dengue fever, West Nile Virus, Lyme disease, and malaria.
These simplified slides by Dr. Sidra Arshad present an overview of the non-respiratory functions of the respiratory tract.
Learning objectives:
1. Enlist the non-respiratory functions of the respiratory tract
2. Briefly explain how these functions are carried out
3. Discuss the significance of dead space
4. Differentiate between minute ventilation and alveolar ventilation
5. Describe the cough and sneeze reflexes
Study Resources:
1. Chapter 39, Guyton and Hall Textbook of Medical Physiology, 14th edition
2. Chapter 34, Ganong’s Review of Medical Physiology, 26th edition
3. Chapter 17, Human Physiology by Lauralee Sherwood, 9th edition
4. Non-respiratory functions of the lungs https://academic.oup.com/bjaed/article/13/3/98/278874
Title: Sense of Taste
Presenter: Dr. Faiza, Assistant Professor of Physiology
Qualifications:
MBBS (Best Graduate, AIMC Lahore)
FCPS Physiology
ICMT, CHPE, DHPE (STMU)
MPH (GC University, Faisalabad)
MBA (Virtual University of Pakistan)
Learning Objectives:
Describe the structure and function of taste buds.
Describe the relationship between the taste threshold and taste index of common substances.
Explain the chemical basis and signal transduction of taste perception for each type of primary taste sensation.
Recognize different abnormalities of taste perception and their causes.
Key Topics:
Significance of Taste Sensation:
Differentiation between pleasant and harmful food
Influence on behavior
Selection of food based on metabolic needs
Receptors of Taste:
Taste buds on the tongue
Influence of sense of smell, texture of food, and pain stimulation (e.g., by pepper)
Primary and Secondary Taste Sensations:
Primary taste sensations: Sweet, Sour, Salty, Bitter, Umami
Chemical basis and signal transduction mechanisms for each taste
Taste Threshold and Index:
Taste threshold values for Sweet (sucrose), Salty (NaCl), Sour (HCl), and Bitter (Quinine)
Taste index relationship: Inversely proportional to taste threshold
Taste Blindness:
Inability to taste certain substances, particularly thiourea compounds
Example: Phenylthiocarbamide
Structure and Function of Taste Buds:
Composition: Epithelial cells, Sustentacular/Supporting cells, Taste cells, Basal cells
Features: Taste pores, Taste hairs/microvilli, and Taste nerve fibers
Location of Taste Buds:
Found in papillae of the tongue (Fungiform, Circumvallate, Foliate)
Also present on the palate, tonsillar pillars, epiglottis, and proximal esophagus
Mechanism of Taste Stimulation:
Interaction of taste substances with receptors on microvilli
Signal transduction pathways for Umami, Sweet, Bitter, Sour, and Salty tastes
Taste Sensitivity and Adaptation:
Decrease in sensitivity with age
Rapid adaptation of taste sensation
Role of Saliva in Taste:
Dissolution of tastants to reach receptors
Washing away the stimulus
Taste Preferences and Aversions:
Mechanisms behind taste preference and aversion
Influence of receptors and neural pathways
Impact of Sensory Nerve Damage:
Degeneration of taste buds if the sensory nerve fiber is cut
Abnormalities of Taste Detection:
Conditions: Ageusia, Hypogeusia, Dysgeusia (parageusia)
Causes: Nerve damage, neurological disorders, infections, poor oral hygiene, adverse drug effects, deficiencies, aging, tobacco use, altered neurotransmitter levels
Neurotransmitters and Taste Threshold:
Effects of serotonin (5-HT) and norepinephrine (NE) on taste sensitivity
Supertasters:
25% of the population with heightened sensitivity to taste, especially bitterness
Increased number of fungiform papillae
Report Back from SGO 2024: What’s the Latest in Cervical Cancer?bkling
Are you curious about what’s new in cervical cancer research or unsure what the findings mean? Join Dr. Emily Ko, a gynecologic oncologist at Penn Medicine, to learn about the latest updates from the Society of Gynecologic Oncology (SGO) 2024 Annual Meeting on Women’s Cancer. Dr. Ko will discuss what the research presented at the conference means for you and answer your questions about the new developments.
2. TOPICS TO COVER
1.NEW EQUIPMENTS-
A.ECHOGENIC NEEDLES,ECHOGENIC CATHETERS AND SENSe
B.ULTRASONIC DEVICES-3D,4D,GPS AND CORDLESS USG DEVICES
C.PRESSURE MONITORING DEVICES
2.LEARNING TOOLS-
A.PHANTOMS
B.ROBOTS
3.PHARMACOLOGY-
A.LIPOSOMAL BUPIVACAINE
B.PROLIPOSOMAL ROPIVACAINE
C.ADJUVANTS TO PROLONG PERIPHERAL NERVE BLOCKS
3. TOPICS TO COVER
4.NEWER NERVE BLOCKS-
A.ERECTOR SPINAE BLOCK
B.RHOMBOIDES BLOCK
C.SHAMROCK BLOCK
D.ARTICULATING BRACH OF FEMORAL NERVE BLOCK
E.TRANSVERSALIS FASCIA PLANE BLOCK
F.COSTOCLAVICULAR BLOCK
5.LIA-LOCAL INFILTRATION ANALGESIA
6.SOME NEW TECHNIQUES IN PAIN MEDICINE
POSTAMPUTATION PAIN T/T
FREEZING SENSORY NERVE BLOCK PRIOR TO KNEE SX /CRYOANALGESIA
4. ECHOGENIC NEEDLES AND
CATHETERS
ECHOGENIC NEEDLES ARE MADE SO AS TO INCREASE THE REFLECTION OF
ULTRASONIC WAVES BACK TO THE TRANSDUCER
THIS IS ACHIEVED BY INCREASING THE VISUAL CONTRAST BETWEEN THE
NEEDLE AND THE SURROUNDING TISSUE BY- COATING THE NEEDLE WITH
TEFLON OR POLYMER ,TEXTURING,DIMPLING,ROUGHENING ETC
THESE NEEDLES PRODUCE FEWER ARTIFACTS AND HAVE A REDUCED IMPACT
ON THE NEEDLE HANDLING AND FEEL.
Limited data exist regarding the echogenicity of perineural catheters, but
visualization is crucial to ensure accurate placement and efficacy of the
subsequent local anesthetic infusion.
8. ECHOGENIC CATHETERS
Includes: 20 Ga. x 55 cm Contiplex Echo Open-tip Catheter with
Stylet and Threading Assist Guide, Contiplex Tuohy Ultra Needle,
Sideport Valve, and Catheter Connector
9. SENSE(SEQUENTIAL ELECTRICAL
NERVE STIMULATION)
Alternating sequential electrical pulses(3) of differing pulse durations at a set frequency of 3 Hz
High pulse durations increase sensitivity
The third impulse has longer reach into the tissue.
Muscle twitches at 3Hz per second indicate needle is positioned closer to the nerve
The impulse duration of the third impulse decreases with stimulus amplitude below 2.5 mA
10.
11. SENSE…ADVANTAGES
Clinically, there is more motor response information at distance from the nerve. Moving
the needle toward the nerve increases the strength or frequency of the motor response.
Continuous feedback and markedly diminishes the disappearance of motor responses
once they are encountered
Increases visual clues and feedback
Less necessity to adjust the amperage control of the nerve stimulator.
13. USG…
3D-Mechanical/matrix probe
Mechanically swept transducer inside a standard probe that moves
through a known trajectory –obtains 2D scans that are converted to
3D images
Matrix array transducer utilizes more than 2400 peizo electric
elements –acquire a direct 3D image
4D-Simultaneous visualisation of multiple planes of view
Spatial relationship between anatomical structures of interest
Measuring local anesthetic spread and tracking fluid dissipation in
fascial compartments
GPS USG-Electromagnetic sensors are mounted on both the
transducer and needle tip
These sensors enable the device to determine actual needle tip
position in relation to the transducer
14. USG ADVANCES..ADVANTAGES
3D-PROVIDES MORE DETAILED ANATOMICAL INFORMATION AND
BETTER SPATIAL ORIENTATION THAN 2D IMAGE.
4D-IT ENHANCES THE VISUALISATION OF A PARTICULAR ANATOMY
AND OFFERS REAL TIME ASSESSMENT OF LOCAL ANESTHETIC SPREAD
DURING USG RA TECHNIQUES.(BASICALLY A LIVE 3D WHERE TIME IS
THE FOURTH DIMENSION)
GPS IN USG-ELECTROMAGNETIC TRACKING CAN FACILITATE NEEDLE
BEAM ADJUSTMENTS FOR IN PLANE APPROACH AND INDICATES WHERE
THE NEEDLE CROSSES THE BEAM DURING OUT OF PLANE USG
TECHNIQUE.
HANDHELD USG AND CORDLESS PROBE ALLOWS EASY USE AND EASY
AVAILABILITY AND PORTABILITY ,CAN BE USED DURING EMERGENCY
LIKE TRAUMA CASES FOR AIRWAY ANATOMY,IN CASES OF EMERGENCY
TRACHEOSTOMY OR CASES WITH DISTORTED AIRWAY
ANATOMY.(MATRIX TRANSDUCERS ARE LIGHTER)
15.
16.
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23.
24.
25.
26. PRESSURE MONITORING DEVICES
These are disposable manometer to monitor injection pressure during
performance of peripheral nerve blocks.
It provides visual indication of injection pressure.
The syringe feel method for assessing the injection force is inconsistent and
thus this provides objective method of monitoring and documenting
injection pressure irrespective of who performs it.
One such example is B-Smart injection pressure monitor.
Intrafascicular injections->15 Psi-associated with severe fascicular injury
and persistent neurological deficits
97% detection of needle nerve contact
(>=15 Psi),intraneural inflammatory changes
Perineural injections typically <4 Psi
Thus is a preventable complication.
27. HOW TO USE IT?
Priming the B-Smart Pressure Monitor 1. Attach the B-Smart monitor to filled syringe
2. Attach needle tubing to the B-Smart monitor 3. Flush system, ensuring the B-
Smart monitor’s piston rises so “> 20 psi” (orange) is visible. The B-Smart monitor’s
piston must move upward during priming in order for the device to be ready to use.
It may be helpful to obstruct the injection tubing to accomplish this.
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2
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28. LEARNING TOOLS-PHANTOMS
Calibration and testing of diagnostic ultrasound machines requires accurate
representation and sonographic characteristics of human tissue.
The physical properties, including speed of sound and attenuation, are tailored to
be the same as those of human tissue
TYPES OF PHANTOMS-
• Water
• Agar
• Gelatin
Elastomeric rubber-BLUE PHANTOMS (BETTER TACTILE FEEDBACK,NO
REFRIGERATION REQD. AND LESS NEEDLE TRACK ARTIFACTS,REUSABLE MULTIPLE
TIMES BUT EXPENSIVE AND DIFFICULT TO PREPARE)
Other option-
• Meat and Cadavers.
29. PHANTOMS-
PROPERTIES OF A GOOD PHANTOM-ECHOGENECITY OF HUMAN
TISSUE,READILY AVAILABLE,INEXPENSIVE,REUSABLE,GIVES TACTILE
FEEDBACK,HOLDS NEEDLE IN PLACE AND DOESN’T GENERATE NEEDLE
TRACKS AND NO EXPOSURE TO HEALTH HAZARDS.
Water phantoms- development and investigation of new UGRA techniques
Non-meat- practising needle placement
Meat based-realistic tissue feedback,local anaesthetic injection
Cadaver based-realistic environment
30.
31.
32.
33. Sample sonogram of a nonanatomic inorganic phantom for
ultrasound-guided regional anesthesia.
Sample sonogram of an organic phantom for ultrasound-guided
regional anesthesia using a porcine meat specimen with inserted
bovine tendon to represent the target “nerve” (arrowheads
identify the tendon).
34. LEARNING TOOLS-ROBOTS
MAGELLAN ROBOTIC NERVE BLOCK SYSTEM
PARTS-
1.Thrustmaster-joystick with two handles
2. JACO-Robotic arm
3. Software control system
4. Graphical user interface
35.
36.
37.
38.
39. ADVANCES IN PHARMACOLOGY
A.LIPOSOMAL BUPIVACAINE (EXPAREL-Brand name)
Liposomes are microscopic structures consisting of a phospholipid bilayer
encapsulating an aqueous core
UNILAMELLAR-single lipid bilayer surrounding the aqueous core
MULTILAMELLAR-concentric lipid bilayers
MULTIVESICULAR-nonconcentric lipid bilayers
40. LIPOSOMAL BUPIVACAINE
LIPOSOMAL BUPI IS FORMULATED TO DELIVER BUPI SLOWLY OVER
TIME TO EXTEND ITS DURATION OF ACTION.
DEPOFOAM IS A PRESERVATIVE FREE AQUEOUS SOLUTION OF
MULTIVESICULAR LIPOSOMES CONTAINING BUPI AT A
CONCENTRATION OF 13.3 MG/ML(EXPRESSED AS AN ANHYDROUS
BUPI HCL EQUIVALENT )AND PLUS 3 % FREE BUPIVACAINE.
THIS FORMULATION PRODUCES TWO PEAKS ONE AFTER FREE
BUPIVACAINE ACTS (FIRST ORDER RELEASE) AND OTHER AFTER
GRADUAL RELEASE OF BUPIVACAINE (SECOND ORDER RELEASE).
TMAX (TIME TO PEAK PLASMA CONC.) IS 12 HR FOR LIPOSOMAL BUPI
V/S 0.6 HR FOR BUPI HCL.
41. PEG LIPOSOMES...
BIOFUNCTIONALIZING THE LIPOSOMES WITH POLYETHYLENE
GLYCOL(PEG),PREVENTS THE INTERACTION BETWEEN THE LIPOSOMAL
NANOVESICLES AND THE MONONUCLEAR PHAGOCYTIC SYSTEM AND
OBTAINS A HIGHER PHARMACOKINETIC RESPONSE.
42. PROLIPOSOMAL ROPIVACAINE
NEW PRODUCT DEVELOPED AND TESTED BY DR. YEHUDA GINOSAUR
OF HEBREW UNIVERSITY,JERUSALEM.FIRST TESTED IN PIGS WHERE
SINGLE DOSE STAYED FOR 4 DAYS THEN IN HUMANS.
IN HUMANS AFTER INJECTION ANESTHESIA TO PINPRICK LASTED ON
AN AVG OF 29 HRS V/S 16 HRS IN PLAIN ROPIVACAINE.
FOR HEAT AND PAIN SENSATION IT LASTED FOR 36 HRS V/S 12 HRS
FOR PLAIN BUPIVACAINE.
BUT IN THIS TEST 4 % ROPIVACAINE FORMULATION WAS USED,
ALMOST 8 TIMES THE DOSE NORMALLY USED.
43. PROLIPOSOMAL ROPIVACAINE
ADVANTAGES OVER OTHER LIPOSOMAL AND PLAIN PREPARATIONS-
IT DOESNOT BECOME LIPOSOMAL UNTIL INJECTED AND CAME IN
CONTACT WITH AQUEOUS SOLUTION I.E, PLASMA AND HENCE THE
NAME PROLIPOSOMAL.
CURRENT LIPOSOMAL PPTNS HAVE A SHELF LIFE OF 1-2 MONTHS AND
PROLIPOSOMAL ROPIVACAINE OIL HAS A SHELF LIFE OF 2 YEARS EVEN
AT ROOM TEMPERATURE.
IT IS ALSO EASY TO PREPARE.
IT COULD SIGNIFICANTLY EXTEND DURATION OF PAIN CONTROL
AFTER INFILTRATION OF LOCAL ANESTHETICS-A WORTHY BUT SO FAR
ELUSIVE GOAL.
44. Liposome-encapsulated ropivacaine for topical anesthesia of human oral mucosa.
Franz-Montan M1, Silva AL, Cogo K, Bergamaschi Cde C, Volpato MC, Ranali J, de Paula
E, Groppo FC.
Adductor Canal Block With Bupivacaine Liposome Versus Ropivacaine Pain Ball for Pain Control in
Total Knee Arthroplasty: A Retrospective Cohort Study.
Wang Y1, Klein MS2, Mathis S2, Fahim G3.
Liposomal bupivacaine demonstrated statistically
significant impact in pain control in the first 36
hours, but by the end of the 72-hour interval, it was
comparable to RPB in postoperative pain
management. Using bupivacaine liposome did
provide direct and total cost savings compared with
RPB.
45. ADJUVANTS TO PROLONG
PERIPHERAL NERVE BLOCKSMany studies have been done on adjuvants to local anesthetics to prolong action
of nerve blocks.
Various adjuvants studies are many as follows-
1.DEXAMETHASONE
2.CLONIDINE
3.DEXMETEDOMIDINE
4.SODIUM BICARBONATE
5.EPINEPHRINE
6.MAGNESIUM
7.MIDAZOLAM
8.TRAMADOL
9.BUPRENORPHINE
10.KETAMINE
46. ADJUVANTS…
DEXAMETHASONE-10 mg dose prolongs action by 10 hrs acc to one
study but no definitive and detailed study available,maximum clinical
trials have found it to be not so effective.
CLONIDINE-150 mcg dose prolonged analgesia in one study by 2
hrs,one more study showed shorter motor blockade duration when
added to ropivacaine than with bupivacaine, but found to have
neurotoxic effects according to another study.
SODIUM BICARBONATE-found to have shorter onset time in a study
but overall in others no significant increase in duration of action
,neurotoxicity profile unknown.
EPINEPHRINE-prolongs duration of action of LA but decreases blood
supply to neural tissue,still recommended as IV injection marker in
dose of 2.5mcg/ml ,if giving in block in ways other than USG
47. ADJUVANTS
MAGNESIUM-prolongs duration of action but further studies required for its
efficacy and neurotoxicity profile.
MIDAZOLAM -not recommended infact found to be neurotoxic.
KETAMINE- not recommended infact found to be neurotoxic.
BUPRENORPHINE-prolongs analgesic action by 12 hrs but side effects nausea
vomiting are distressing,also not studied in detail.
TRAMADOL-in dose of 1.5 mg/kg has not been found to be very efficacious.
48. DEXMEDETOMIDINE
Study by Kettner et al in Austria shows a significant increases in duration of
action when added in peripheral nerve blocks .
It acts by blocking the hyperpolarization activated cation current in the
peripheral nerves,renders them refractory to stimulation.
Fristch et al found 150 mcg hastened sensory and motor block and
prolongation by 240 min with no hemodyanamic instability.
Marhofer et al found as low as 20 mcg prolonged ulnar nerve sensory block
by 248 min and motor block by 205 min.
Sandhya Agarwal et al found 100 mcg shortens the onset time and
prolonged the duration of action significantly when mixed with 0.325 %
bupivacaine ,755 min sensory v/s 234 min and 702 min for motor block v/s
208 min.
Surprisingly,both motor and sensory block prolongation found with iv
administration of dexmed 20 mcg by 45 and 90 min respectively.(FDA
approved)
It appears to be a promising upcoming drug for peripheral nerve blocks.
50. ERECTOR SPINAE BLOCK
ERECTOR SPINAE MUSCLE ORIGINATES FROM SPINOUS PROCESS OF T9
TO T12 THORACIC VERTEBRAE AS WELL AS THE MEDIAL SLOPE OF THE
DORSAL SEGMENT OF THE ILIAC CREST.
IT GETS INSERTED TO THE SPINOUS PROCESS OF T1 AND T2
THORACIC VERTEBRAE AND THE CERVICAL VERTEBRAE AS WELL.
IT IS A GROUP OF MUSCLES ,ILIOCOSTALIS LATERALLY,LONGISSIMUS
INTERMEDIATE AND SPINALIS MEDIALLY.
IT RUNS THROUGHOUT LUMBAR,THORACIC AND CERVICAL REGION IN
GROOVE TO THE SIDE OF THE VERTEBRAL COLUMN.
51.
52.
53.
54. ERECTOR SPINAE BLOCK
DESCRIBED BY MAURICIO FORERO ET AL
IT’S A MULTIDERMATOMAL SENSORY BLOCK T2-T9
ACTS ON DORSAL AND VENTRAL RAMI OF THORACIC SPINAL NERVES
BENEFITIAL FOR NEUROPATHIC PAIN LIKE METASTASIS TO RIBS OR MALUNION
AFTER MULTIPLE RIB FRACTURES,POSTSURGICAL AND POST TRAUMATIC
PAIN.
PROVIDES PAIN RELIEF UPTO 36 HOURS.
55. ERECTOR SPINAE BLOCK
TECHNIQUE-PROBE IS PLACED IN LONGITUDINAL ORIENTATION OVER TIP OF
T5 TRANSVERSE PROCESS AND BOCK NEEDLE IS ADVANCED CEPHALAD TO
CAUDAD DIRECTION TO CONTACT THE TRANSVERSE PROCESS THEN
WITHDRAWN TO GIVE DRUG.
DRUG CAN BE DEPOSITED EITHER ABOVE ERECTOR SPINAE(TYPE 1,LESS
EFFICACIOUS)
OR CAN BE DEPOSITED BELOW ERECTOR SPINAE AND TRANSVERSE
PROCESSES(TYPE 2,MORE LINEAR SPREAD WITH BETTER RESULTS)
AREA COVERED-T2-T9 ,3CM LATERAL TO THE THORACIC SPINE TO
MIDCLAVICULAR LINE,ALSO AXILLA AND MEDIAL UPPER PART OF ARM GETS
THE SENSORY BLOCKADE
DRUG -0.25 % BUPIVACAINE 20 ML
6-13 MHZ LINEAR USG PROBE IN SITTING POSITION.
60. ADVANTAGES OF ERECTOR SPINAE
BLOCK
EASY SONOANATOMY
SAFER AND SIMPLE BLOCK V/S INTERCOSTAL AND PARAVERTEBRAL WHICH ARE
MORE INVASIVE THUS CAN BE USED AS AN OPD BLOCK.
PECTORAL AND SERRATUS ANTERIOR BLOCK DOESNOT COVER THE VAST
SENSORY BLOCK AREA V/S ERECTOR SPINAE BLOCK AS IT COVERS AXILLA AND
ANTEROLATERAL CHEST WALL AREA AS WELL.
CATHETER CAN BE PUT FOR LONG TERM USE AS WELL.
MORE STUDIES ARE REQUIRED TO CHECK ITS EFFICACY.
61. RHOMBOIDES BLOCK
DESCRIBED BY H.ELSHARKAWY ET AL.
PECTORAL AND SERRATUS PLANE BLOCK DON’T COVER THE POSTERIOR PRIMARY
RAMI WHICH CAN BE ACHIEVED BY INFILTRATION OF LOCAL ANESTHETICS INTO
INTERFASCIAL PLANE ON POSTERIOR CHEST WALL IN TRIANGLE OF
AUSCULTATION (TOA)KNOWN AS RHOMBOIDES BLOCK.
TOA IS LOCATED ALONG LOWER MEDIAL BORDER OF SCAPULA
BOUNDARIES-
SUPERIORLY-TRAPEZIUS
INFERIORLY-LATISSIMUS DORSI
LATERALLY-VERTEBRAL BORDER OF SCAPULA
FLOOR IS FORMED BY LOWER PART OF RHOMBOID MAJOR,LATERAL PART OF
ERECTOR SPINAE AND SERRATUS ANTERIOR MUSCLES OVERLYING 6TH TO 7TH RIBS
AND THEIR INTERNAL AND EXTERNAL INTERCOSTAL MUSCLES.
62. RHOMBOIDES BLOCK
TISSUE PLANE BETWEEN FLOOR OF TOA (RHOMBOIDES MAJOR) AND THE
INTERCOSTALS EXTENDS MEDIALLY BELOW ERECTOR SPINAE,LATERALLY
CROSSES MIDAXILLARY LINE BELOW SERRATUS ANTERIOR.
PATIENT POSITION-PRONE AND ARMS ADDUCTED ACROSS THE CHEST TO
PUSH THE SCAPULA LATERALLY.
LINEAR USG PROBE (6-13 MHZ) PLACED MEDIAL TO THE LOWER BORDER OF
SCAPULA WITH THE MARKER DIRECTED CRANIALLY.
PLANE IS IDENTIFIED ,SINGLE INJECTION GIVEN AT T6-T7 LEVEL
25 ML OF 0.25 % BUPIVACAINE
AREAS COVERED-T2-T9 ,ANTERIOR HEMITHORAX JUST MEDIAL TO THE
MIDLINE ,LATERAL FROM AXILLA TO T9 AND POSTERIOR HEMITHORAX UPTO
MEDIAL OF THE MIDLINE.THUS COVERS MORE AREA V/S ERECTOR SPINAE.
FURTHER MORE STUDIES ARE REQUIRED LOOKS PROMISING.
63.
64.
65. ARTICULATING BRANCH OF
FEMORAL NERVE (ABFN)BLOCK
It is a new block ,few studies done and shown to have a good post
operative pain relief profile in patients undergoing Hip Arthroplasty
(as necessity of good pain relief as well as mobilisation)
This block involves very less side effects.
Anatomy of ABFN-
ANTERIORLY-SARTORIUS
LATERALLY-RECTUS FEMORIS
MEDIALLY-ILIACUS
66. ABFN …
Typically Obturator nerve block was used to relieve hip pain uptil now
but found to have a lot of sparing.
This led to some anatomical studies eg K.Birhaum et al who
concluded following-
HIP JOINT CAPSULE SUPPLY-
ANTEROMEDIAL-ARTICULAR BR OF OBTURATOR NERVE
ANTERIOR-SENSORY ARTICULAR BR OF FEMORAL NERVE(ABFN)
POSTERIOR-ARTICULAR BR OF SCIATIC NERVE
POSTEROMEDIAL-ARTICULAR BR OF NERVE TO QUADRATUS FEMORIS
THUS FOR COMPLETE PAIN RELIEVE NEED TO BLOCK ALL THREE-
OBTURATOR,FEMORAL AND SCIATIC ARTICULAR BRANCHES.
68. ABFN TECHNIQUE
LANDMARK-3-4 CM CAUDAL TO THE INGUINAL LIGAMENT
PROBE-LINEAR 6-13 MHZ
DRUG-20 ML 0.25 % BUPIVACAINE AND 4 MG DEXAMETHASONE
TECHNIQUE-OUT OF PLANE USG GUIDED
NEEDLE-3.5CM HYPODERMIC 23 G NEEDLE
IDENTIFICATION-IT’S A HYPERECHOIC TRIANGULAR TO OVAL
STRUCTURE,0.5-1 CM IN DIAMETER
69. REPRESENTATION OF ABFN AND ITS RELATION TO
MUSCLES AND FEMORAL VESSELS AND NERVE
SARTORIUS
RECTUS FEMORIS
A
B
F
A
71. SHAMROCK BLOCK
TRANSVERSE USG SCAN ,PROBE IS PLACED CRANIALLY TO THE ILIAC
CREST ,FOR LUMBAR PLEXUS BLOCK
FIRST DESCRIBED IN 2013 BY SAUTER ET AL
PSOAS MAJOR MUSCLE IS SEEN ANTERIOR TO THE TRANSVERSE
PROCESS,ERECTOR SPINAE IS POSTERIOR TO THE TRANSVERSE
PROCESS,QUADRATUS LUMBORAM IS AT THE APEX OF THE
TRANSVERSE PROCESS L4
EASILY RECOGNISABLE PATTERN OF SHAMROCK,THREE LEAVES IS SEEN
ON USG
DEPOSIT LA POSTERIOR TO THE PSOAS MAJOR MUSCLE.
72.
73.
74.
75. The Shamrock lumbar plexus block: A dose-finding study.
Sauter AR1
, Ullensvang K, Niemi G, Lorentzen HT, Bendtsen TF, Børglum J, Pripp AH, Romundstad L.
Author information
Avolumeof20.4 mlropivacaine0.5%providedasuccessfulShamrocklumbarplexusblockin50%of
thepatients.Avolumeof36.0 mlwouldbesuccessfulin95%ofthepatients.
76. COSTOCLAVICULAR BLOCK
(PROXIMAL APPROACH OF
INFRACLAVICULAR BLOCK)
COSTOCLAVICULAR SPACE BOUNDARIES-deep and posterior to
middle of clavicle
ANTERIORLY-CLAVICLE
MEDIALLY-FIRST RIB
POSTERIORLY-SCALENUS ANTERIOR
LATERALLY-COSTOCLAVICULAR LIGAMENT AND SUBCLAVIUS MUSCLE
CONTENTS-
BRACHIAL NERVE PLEXUS
AXILLARY ARTERY
AXILLARY VEIN
81. COSTOCLAVICULAR BLOCK…
ADVANTAGES-
AS COMPARED TO INFRACLAVICULAR FOSSA LATERALLY, HERE ALL
THREE CORDS ARE QUITE SUPERFICIAL AND CLUSTERED
TOGETHER,LATERAL TO AXILLARY ARTERY.
VERY RAPID ONSET SIMILAR TO SUPRACLAVICULAR BLOCK AND ALSO
LESS CHANCES OF SPARING OF THE LOWER TRUNK.
CATHETER CAN BE PLACED EASILY AND THAT TOO VERY CLOSE TOO
ALL THREE CORDS.
CATHETER DISPLACEMENT CHANCES ARE MINIMAL AS LIES DISTALLY
IN INTERMUSCULAR TUNNEL (SUBCLAVIUS AND SERRATUS ANTERIOR
MUSCLES).
82. TRANSVERSALIS FASCIA PLANE
BLOCKThe transversalis fascia plane block, or TFP block, is a truncal block that targets the L1 nerve
branches, namely the ilioinguinal and iliohypogastric nerves.
These nerves emerge from the lateral border of psoas major muscle, inferior to the 12th rib,
and course over the anterior surface of the quadratus lumborum muscle finally enter the
transversus abdominis plane between the internal oblique and transversus abdominis
muscles.
The TFP block targets the ilioinguinal and iliohypogastric nerves where they are between
the fascia of the transversus abdominis muscle and the transversalis fascia.
The fascia of the transversus abdominis muscle, also called the thoracolumbar fascia, is
formed when the transversus abdominis and internal oblique muscles taper off posteriorly
into a common aponeurosis.
83. TFP
INDICATIONS-
The TFP block is indicated for pain relief following anterior iliac crest bone
graft harvesting as the block is performed proximal to the L1 branches that
innervate the anterior iliac crest.
Local anesthetic spread can also involve the subcostal nerve (T12 spinal
nerve). This block is also an analgesic option for inguinal hernia repair, open
appendectomy and any surgery involving the L1 dermatome.
84. TFP V/S TAP
The TFP block is designed to block the L1 nerve branches, which the TAP block
does not reliably cover.
Local anesthetic is injected deep to the transversus abdominis muscle for the
TFP block versus superficial to the muscle for the TAP block.
The site of TFP injection is posterior to the mid-axillary line, unlike the classic
ultrasound-guided TAP block.
85.
86. Internal Oblique Muscle
Transversus Abdominis Muscle
External Oblique Muscle
External oblique m usc
le
Internal oblique m usc
le
Transversus a bdominis
Quadratus l umborum
87.
88.
89. LOCAL INFILTRATION ANALGESIA-
LIA
Local infiltration analgesia (LIA) is an analgesic technique that has
gained popularity since it was first brought to widespread attention by
Kerr and Kohan in 2008.
The technique involves the infiltration of a large volume dilute
solution of a long-acting local anesthetic agent, often with adjuvants
(e.g., epinephrine, ketorolac, an opioid), throughout the wound at the
time of surgery.
The analgesic effect duration can then be prolonged by the placement
of a catheter to the surgical site for postoperative administration of
further local anesthetic.
The technique has been adopted for use for postoperative analgesia
following a range of surgical procedures (orthopaedic<knee and hip
surgeries>, general, gynecological, and breast surgeries).
90. Analgesic efficacy of local infiltration analgesia in hip and knee
arthroplasty: a systematic review
1. L. . Andersen
2. H. Kehlet
LIA provides effective analgesia in the initial postoperative
period after TKA in most randomized clinical trials even when
combined with multimodal systemic analgesia.
Local infiltration analgesia: a technique for the control of
acute postoperative pain following knee and hip surgery: a
case study of 325 patients.
Kerr DR1, Kohan L.
Local infiltration analgesia is simple, practical, safe, and
effective for pain management after knee and hip surgery.
91. LIA..ADVANTAGES
IT ALLOWS EARLY MOBILISATION.
IT SAVES THE HOSPITAL COSTS AS EARLY DISCHARGE.
INVOLVES NO COMPLICATIONS LIKE HYPOTENSION,QUADRICEPS MUSCLE
WEAKNESS,URINARY RETENTION ETC.
A NUMBER OF INVESTIGATORS HAVE FOUND LIA TO BE SUPERIOR TO
PLACEBO/NO INFILTRATION AND EPIDURAL ANALGESIA IN TERMS OF
POSTOPERATIVE ANALGESIA SCORES,JOINT FUNCTION/REHABILITATION,AND
LENGTH OF HOSPITAL STAY.
Peripheral nerve blockade (PNB) has been shown to provide equivalent
analgesia compared to epidural analgesia with the benefit of a lesser
incidence of hypotension and urinary retention , however PNB requires a
high level of expertise to perform,?QUADRICEPS WEAKNESS.
Choi et al. reviewed the use of epidural analgesia for pain relief following hip
(and knee) replacement in a Cochrane review in 2003 and concluded that the
beneficial effect of epidural analgesia was limited to 4–6 hours
postoperatively, and side effects (hypotension, pruritus, urinary retention)
were more frequent with epidural analgesia compared to systemic analgesia
92.
93. OTHER NEWER TECHNIQUES IN
PAIN MEDICINEPostamputation residual limb pain is often a disabling chronic pain that is
refractory to current pain management modalities, such as medications,
peripheral nerve blocks or denervation,Using high-frequency alternating
current via a peripheral nerve cuff electrode creates a complete depolarizing
nerve block, which blocks painful or unwanted nerve transmission of pain
signals; the cuff is placed proximal to the neuroma at the end of the severed
nerve. This therapy yielded >50% pain reduction.More studies required.
PERCUTANEOUS FREEZING OF SENSORY NERVES PRIOR TO TKR
Percutaneous cryoneurolysis targeting the infrapatellar branch of the saphenous
nerve and anterior femoral cutaneous nerve could relieve post-operative knee
pain by temporarily blocking sensory nerve conduction. The treatment group
reported a statistically significant reduction in symptoms at the six-
and 12-week follow-up compared with the control group.More
studies are required.
94. PAIN MEDICINE…
Cryoanalgesia involves a cryogenic probe under direct fluoroscopy
guidance. A local anaesthetic is used in this procedure to numb the
skin and underlying tissues. A catheter is then inserted into this area.
A cryobrobe is threaded through the catheter. Once the specific nerve
area is identified, the freezing process begins(less than -20 degree
Celsius is effective). This can take 2-3 minutes and may be repeated
in order to cover one’s pain.
Cryoanalgesia can be utilized for treating small well localized lesions
of nerves, perineal pain, lower extremity pain, post-herpetic
neuralgia , and facial and cranial pain.
It has also been used to obtain pain relief in biomechanical pain
syndromes including lumbar or cervical facet syndromes, and
coccygodynia, and to treat post-surgical pain .
The most common use for cryoanalgesia for lower back pain is the
long term treatment of lumbar facet pathology.