Neuraxial anesthesia is a term that denotes all forms of central blocks, involving the spinal, epidural, and caudal spaces. Epidural anesthesia is a versatile technique widely used in anesthetic practice. Its potential to decrease postoperative morbidity and mortality has been demonstrated by numerous studies. To maximize its perioperative benefits while minimizing potential adverse outcomes, the knowledge of factors affecting successful block placement is essential.  This paper will provide an overview of the pertinent anatomical, pharmacological, immunological, and technical aspects of epidural anesthesia in both adult and pediatric populations and will discuss the recent advances, the related rare but potentially devastating complications, and the current recommendations for the use of anticoagulants in the setting of neuraxial block placement.

Maria Bauer

John E. George

John Seif

Ehab Farag

Recent Advances in Epidural Analgesia

This study investigates the effects of lidocaine pre-emptive treatment on neuropathic pain behavior, injury discharges of nerves, neuropeptide Y (NPY) and c-Fos expression in the cuneate nucleus (CN) after median nerve chronic constriction injury (CCI). Behavior tests demonstrated that the pre-emptive lidocaine treatment dose dependently delayed and attenuated the development of mechanical allodynia within a 28-day period. Electrophysiological recording was used to examine the changes in injury discharges of the nerves. An increase in frequency of injury discharges was observed and peaked at postelectrical stimulation stage in the presaline group, which was suppressed by lidocaine pre-emptive treatment in a dose-dependent manner. Lidocaine pretreatment also reduced the number of injury-induced NPY-like immunoreactive (NPY-LI) fibers and c-Fos-LI neurons within the CN in a dose-dependent manner. Furthermore, the mean number of c-Fos-LI neurons in the CN was significantly correlated to the NPY reduction level and the sign of mechanical allodynia following CCI.

Chi-Te Lin

Yi-Ju Tsai

Hsin-Ying Wang

Seu-Hwa Chen

Tzu-Yu Lin

June-Horng Lue

Pre-Emptive Treatment of Lidocaine Attenuates Neuropathic Pain and Reduces Pain-Related Biochemical Markers in the Rat Cuneate Nucleus in Median Nerve Chronic Constriction Injury Model

The present study aimed to determine whether neonatal treatment with fentanyl has lasting effects on stressed developing brain. Six-day-old rats were assigned to one of three groups (10 males/group): (1) fentanyl (incision+fentanyl), (2) saline (incision+0.9&#37; saline), and (3) unoperated (unoperated sham). Pups with a plantar paw incision received repetitive subcutaneous injections of fentanyl or vehicle through postnatal days (PNDs) 6 to 8. A nonoperated sham group served as nonstressed control. Studies included assessment of development from PND 6 to PND 21 (growth indices and behavioral testing). Fentanyl administered twice daily for three days after surgical incision had no impact on early growth and development, as measured on PND 9, but showed a lasting impact on later growth, enhanced behavioral development, and lower anxiety, as measured through PNDs 10&#8211;21. While this does not completely support a benefit from such treatment, our findings may contribute to support the neonatal use of fentanyl, when indicated, even in premature newborns.

Dora Catr&#233;

Maria Francelina Lopes

Ant&#243;nio Silv&#233;rio Cabrita

Lasting Developmental Effects of Neonatal Fentanyl Exposure in Preweanling Rats

The use of neuromodulation for pain relief is among the fastest-growing areas of medicine, involving many diverse specialties and impacting on hundreds of thousands of patients with numerous disorders worldwide. As the evidence of efficacy improves, the interest in spinal cord stimulation (SCS) will increase because it is minimally invasive, safe, and a reversible treatment modality with limited side effect profile. While the mechanism of action evades complete understanding, the technological improvements have been considerable and current neuromodulation developments have been coupled with the rapid growth of the neuromodulation device industry resulting in the development of the next-generation neuromodulation systems. The development, the newest technicaliti and the future for the clinical application of spinal cord stimulation (SCS) are reviewed here.

Dominic Hegarty

Spinal Cord Stimulation: The Clinical Application of New Technology

Trigger point injections are commonly practised pain interventional techniques. However, there is still lack of objective diagnostic criteria for trigger points. The mechanisms of action of trigger point injection remain obscure and its efficacy remains heterogeneous. The advent of ultrasound technology in the noninvasive real-time imaging of soft tissues sheds new light on visualization of trigger points, explaining the effect of trigger point injection by blockade of peripheral nerves, and minimizing the complications of blind injection.

Clara S. M. Wong

Steven H. S. Wong

A New Look at Trigger Point Injections

The accidental overdose of local anesthetics may prove fatal. The commonly used amide local anesthetics have varying adverse effects on the myocardium, and beyond a certain dose all are capable of causing death. Local anesthetics are the most frequently used drugs amongst anesthetists and although uncommon, local anaesthetic systemic toxicity accounts for a high proportion of mortality, with local anaesthetic-induced cardiac arrest particularly resistant to standard resuscitation methods. Over the last decade, there has been convincing evidence of intravenous lipid emulsions as a rescue in local anesthetic-cardiotoxicity, and anesthetic organisations, over the globe have developed guidelines on the use of this drug. Despite this, awareness amongst practitioners appears to be lacking. All who use local anesthetics in their practice should have an appreciation of patients at high risk of toxicity, early symptoms and signs of toxicity, preventative measures when using local anesthetics, and the initial management of systemic toxicity with intravenous lipid emulsion. In this paper we intend to discuss the pharmacology and pathophysiology of local anesthetics and toxicity, and the rationale for lipid emulsion therapy.

Sarah Ciechanowicz

Vinod Patil

Lipid Emulsion for Local Anesthetic Systemic Toxicity

This case report describes the successful treatment of chronic headache from intracranial hypotension with bilateral transforaminal (TF) lumbar epidural blood patches (EBPs). The patient is a 65-year-old male with chronic postural headaches. He had not had a headache-free day in more than 13&#x2009;years. Conservative treatment and several interlaminar epidural blood patches were previously unsuccessful. A transforaminal EBP was performed under fluoroscopic guidance. Resolution of the headache occurred within 5&#x2009;minutes of the procedure. After three months without a headache the patient had a return of the postural headache. A second transforaminal EBP was performed again with almost immediate resolution. The patient remains headache-free almost six months from the time of first TF blood patch. This is the first published report of the use of transforaminal epidural blood patches for the successful treatment of a headache lasting longer than 3&#x2009;months.

Kirk Bowden

Adam Wuollet

Amol Patwardhan

Theodore J. Price

John Lawall

Jeffery Annabi

Steven Barker

Emil Annabi

Transforaminal Blood Patch for the Treatment of  Chronic Headache from Intracranial Hypotension:  A Case Report and Review

The aim of this study was to investigate the anesthetic effect and risk of epinephrine for subcutaneous single injection digital block. Either 3.0&#x2009;mL 1.0&#x25; Lidocaine or a 3.0&#x2009;mL 1.0&#x25; Lidocaine with (1&#x2009;:&#x2009;100,000) epinephrine was injected into the subcutaneous space at the middle point of the palmar digital crease of the 18 middle fingers of 9 healthy volunteers. 
 The SpO<sub>2</sub> of the fingers decreased to a maximum of 97. No subjects showed any symptoms of ischemic injury. The time to anesthesia for the fingers was significantly shorter (<svg style="vertical-align:-0.30096pt;width:56.150002px;" id="M1" height="11.25" version="1.1" viewBox="0 0 56.150002 11.25" width="56.150002" xmlns="http://www.w3.org/2000/svg">
				<g transform="matrix(1.25,0,0,-1.25,0,11.25)">
					<g transform="translate(72,-63)">
						<text transform="matrix(1,0,0,-1,-71.95,63.35)">
							<tspan style="font-size: 12.50px; " x="0" y="0">𝑃</tspan>
							<tspan style="font-size: 12.50px; " x="10.890113" y="0">&lt;</tspan>
							<tspan style="font-size: 12.50px; " x="22.930502" y="0">0</tspan>
							<tspan style="font-size: 12.50px; " x="29.182001" y="0">.</tspan>
							<tspan style="font-size: 12.50px; " x="32.307751" y="0">0</tspan>
							<tspan style="font-size: 12.50px; " x="38.559254" y="0">5</tspan>
						</text>
					</g>
				</g>
			</svg>), and the duration of anesthesia was significantly longer (<svg style="vertical-align:-0.30096pt;width:56.150002px;" id="M2" height="11.0625" version="1.1" viewBox="0 0 56.150002 11.0625" width="56.150002" xmlns="http://www.w3.org/2000/svg">
				<g transform="matrix(1.25,0,0,-1.25,0,11.0625)">
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							<tspan style="font-size: 12.50px; " x="22.930502" y="0">0</tspan>
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						</text>
					</g>
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			</svg>) for the fingers in the epinephrine group. In conclusion, a subcutaneous single injection digital blocks with 3.0&#x2009;mL of 1.0&#x25; Lidocaine and (1&#x2009;:&#x2009;100,000) epinephrine were safe, reducing the time to the onset of anesthesia, while also markedly prolonging the anesthesia.

Motoki Sonohata

Satomi Nagamine

Kazumasa Maeda

Kenji Ogawa

Hideki Ishii

Kenji Tsunoda

Akihiko Asami

Masaaki Mawatari

Subcutaneous Single Injection Digital Block with Epinephrine

About this journal

<p><em>Anesthesiology Research and Practice </em>provides a forum for health care professionals engaged in perioperative medicine, critical care, and pain management. Topics include anesthetic administration, preoperative and postoperative considerations etc.</p>


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<p><em>Anesthesiology Research and Practice </em>maintains an Editorial Board of practicing researchers from around the world, to ensure manuscripts are handled by editors who are experts in the field of study.</p>


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