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Introduction Incarceration of the medial epicondyle is a well-recognised sequelae following closed reduction of the elbow. Manipulation for extraction is not usually successful and hence an incarcerated medial epicondyle is usually an indication for open reduction and fixation. Case presentation We describe a simple technique of closed reduction using a conventional nerve stimulator to extract an incarcerated medial epicondyle in a 13-year-old Caucasian boy. This technique uses contraction of the attached common flexor muscles to indirectly extract the trapped medial epicondyle. Conclusions This is a simple technique using a commonly available nerve stimulator and may obviate the need for extensile open reduction for extraction of the incarcerated medial epicondyle. We would recommend this technique where closed reduction methods have failed.

Summary Regional anaesthesia is a popular choice for patients undergoing carotid endarterectomy (CEA). Neurological function is easily assessed during carotid cross-clamping; haemodynamic control is predictable; and hospital stay is consistently shorter compared with general anaesthesia (GA). Despite these purported benefits, mortality and stroke rates associated with CEA remain around 5% for both regional anaesthesia and GA. Regional anaesthetic techniques for CEA have improved with improved methods of location of peripheral nerves including nerve stimulators and ultrasound together with a modification in the classification of cervical plexus blocks. There have also been improvements in local anaesthetic, sedative, and arterial pressure-controlling drugs in patients undergoing CEA, together with advances in the management of patients who develop neurological deficit after carotid cross-clamping. In the UK, published national guidelines now require the time between the patient's presenting neurological event and definitive treatment to 1 week or less. This has implications for the ability of vascular centres to provide specialized vascular anaesthetists familiar with regional anaesthetic techniques for CEA. Providing effective regional anaesthesia for CEA is an important component in the armamentarium of techniques for the vascular anaesthetist in 2014.

Recurrence of tarsal tunnel syndrome after surgery may be due to inadequate release, lack of understanding or appreciation of the actual anatomy involved, variations in the anatomy of the nerve(s), failure to execute the release properly, bleeding with subsequent scarring, damage to the nerve and branches, persistent hypersensitivity of the nerves, and preexisting intrinsic damage to the nerve. Approaches include more thorough release, use of barrier materials to decrease adherence of the nerve to surrounding tissues to avoid traction neuritis, excisions of neuromas using conduits, and consideration of nerve stimulators and systemic medications to deal with persistent neural pain.

Background and Objectives: The multiple-injection technique for axillary block, in which the main 4 nerves of the plexus are located by a nerve stimulator and separately injected, has been shown to produce a high success rate. However, this technique may prove to be more difficult and time-consuming than other methods. Therefore, a simplified technique, with a reduced number of injections, might be desirable. A comparison between 2- and 3-injection techniques was made in the present double-blind study. Methods: One hundred patients were randomly allocated to 2 groups. In group 3N, the radial, median, and musculocutaneous nerves were located by a nerve stimulator and injections made. In group 2N, the radial and median nerves were located and injections made. Forty milliliters of local anesthetic was used. Results: A greater success rate for anesthetizing the musculocutaneous nerve was found in group 3N (98% v 80%; P [lt ] .005). No differences between the groups were found in the success rate for blocking the radial, median, and ulnar nerves. The rate of complete block (all the sensory areas distal to the elbow) was 90% in group 3N and 76% in group 2N. The time to perform the block was shorter in group 2N (5 [plusmn] 1 v 6 [plusmn] 1 minutes; P [lt ] .001). Conclusions: The 2-injection technique offers a success rate in blocking the 3 nerves innervating the hand similar to that obtained with the 3-injection technique. The latter approach should be considered when the musculocutaneous nerve distribution is involved in the surgical area. Reg Anesth Pain Med 2001;26:499-503.

Objective: To describe the technique of femoral nerve block using a nerve stimulator to locate the nerve, and to report the success rate of its use by junior and senior doctors in the emergency department. Method: Standardized protocol and patient selection criteria were formulated for the performance of femoral nerve block on patients with femoral neck or shaft fractures using a nerve stimulator to locate the femoral nerve and confirm deposition of local anaesthetic agent close to the femoral nerve. Femoral nerve blockade was assessed before and after femoral nerve block by testing for altered sensation in the cutaneous distribution of the femoral nerve. Pain was assessed before and after femoral nerve block using a visual analogue scale. The use of supplementary analgesics was recorded. Results: A successful femoral nerve block was obtained with the nerve stimulator in 19 of 22 attempts (86%) at femoral nerve block. Success was unrelated to seniority of staff. Femoral nerve block was the only analgesia required in 17 patients (77%). Femoral nerve block was the only analgesia required for 100% for femoral shaft fractures and 75% and 73%, respectively, for extra-capsular and intracapsular fractures of the femoral neck. Conclusion: The femoral nerve was accurately located using the nerve stimulator irrespective of seniority of staff performing the procedure. Femoral nerve block using the nerve stimulator was effective analgesia for femoral shaft fractures and the majority of both intra- and extra-capsular femoral neck fractures.

Objectives. To determine the efficacy of peripheral neuromodulation of the S3 region in patients with urgency-frequency syndrome due to an overactive bladder. Methods. Fifteen patients (11 women and 4 men) with urgency-frequency syndrome, as documented by a voiding chart, were diagnosed with overactive bladder. Pelvic pain was assessed by a visual analogue scale (VAS). Full urodynamic workup was performed before and after 12 peripheral stimulations with a 9-V monopolar generator, the so-called Stoller Afferent Nerve Stimulator (SANS). Follow-up was for a mean (SD) of 10.9 (4 to 15) months. Results. Reduction in pain was achieved in all patients, with a decrease in VAS from a mean (SD) of 7.6 (5 to 10) to 3.1 (1 to 7) (P = 0.00049). Seven patients (46.7%) had a complete response and were considered cured, 3 (20.0%) showed significant improvement, and 5 (33.3%) were classified as nonresponders. Urodynamic evidence of bladder instability, evident in all patients before treatment, was eliminated in 76.9% of patients. In all patients, mean (SD) total bladder capacity increased significantly from 197 (35 to 349) to 252 (78 to 384) mL (P = 0.00795), mean (SD) volume at first bladder sensation from 95 (16 to 174) to 133 (32 to 214) mL (P = 0.00166), and mean (SD) bladder volume at normal desire to void from 133 (27 to 217) to 188 (47 to 296) mL (P = 0.00232). In the responding group, the mean (SD) total numbers of voids was reduced from 16.1 (9 to 24) times during the day and 4.4 (2 to 6) times during the night to 8.3 (6 to 10) and 1.4 (1 to 2) times (P = 0.002539), respectively. No complications from treatment were observed. Conclusions. Peripheral neuromodulation of the S3 region can successfully treat patients with urgency-frequency syndrome due to an overactive bladder.

Objective. To analyze the walking pattern in hemiplegic patients using a peroneal nerve stimulator to locate possible harmful mechanical effects on the musculo-skeletal system. Design. Eight hemiplegic patients participated in the study. All patients had used a peroneal nerve stimulator regularly for more than two years and were able to perform unassisted walking. Background. Peroneal nerve stimulators are widely applied for correction of foot-drop in hemiplegic patients. The stimulators do not induce normal dorsi-flexion, but a rather exaggerated dorsi-flexion and eventually eversion which might be harmful. Methods. Three-dimensional kinematic and kinetic analyses of the walking patterns at self-selected speeds were performed with the patients walking without the stimulator and with the stimulator turned on. Results. The walking speed increased on average from 0.77 (S.D., 0.83) to 0.84 (S.D., 0.11) (7.6%, P=0.005) when the stimulator was used, however no uniform changes in the walking pattern and joint loads were observed. The total work (generation + absorption) produced by the affected leg (both with and without the peroneal nerve stimulator) was significantly lower (P=0.005) than that of the contralateral leg. Deviations from normal power profiles were observed both on the affected and the contralateral side, and the walking efficiency was 57% lower compared to normal subjects. The estimated peak bone-on-bone forces corresponded to about 50% of what previously has been observed during normal walking at self-selected speed. Conclusions. The use of the peroneal nerve stimulator do not introduce any excessive and potential harmful mechanical loads. Relevance Applied correctly, the peroneal nerve stimulator can be used as an aid for foot-drop correction in hemiplegic patients without causing excessive wear on the joints in the lower extremity.

The authors report a newly devised nerve stimulator and its clinical application in thoracoscopic surgery. The stimulator is a monopolar system, that has a long extension between the electrodes and the handle. The stimulator is inserted into the chest cavity through a portal, and is used to distinguish motor nerves from the surrounding tissue and to determine whether there is nerve involvement with tumor. The tumor is then safely and rapidly resected by thoracoscopic technique and the major nerves are spared. This method was used in two clinical cases, with excellent results obtained, and with no major complications.

The subclavian perivascular technique, introduced by Winnie and Collins in 1964, is one of the most popular supraclavicular approaches to the brachial plexus. It is based on an anatomical concept, the existence of a fibrous tissue sheath surrounding the neurovascular bundle. This sheath acts as a barrier, limiting the diffusion of the local anesthetic away from the nerves. Thus, a single injection of an adequate volume of local anesthetic within this space is able to reach the components of the plexus, consistently producing good results. Different methods are employed to identify the presence of the needle inside the sheath. A fascial “click”, used by some, is a subjective sensation felt by the operator when the needle pierces the fascia. More popular is the technique of eliciting paresthesias. It requires physical contact between needle and nerve, as well as the patient's cooperation to qualify and locate the response. The possibility of increased risk of nerve damage has been raised with this technique. Lately, nerve stimulators have enjoyed increased popularity. They have the theoretical advantage of helping to bring the needle close enough to the nerve to ensure intrafascial injection, without the need for physical contact. The subclavian perivascular block, performed with a nerve stimulator, makes an already good technique even better.

The importance of selecting approapriate devices (eg, needles, catheters, and nerve stimulators) to perform a regional block in children has long been underestimated. This attitude is no longer acceptable because it is now established that half the complications currently reported after performance of a regional block in children are related to the use of the wrong device. Specifically, devices are now available for virtually all types of regional block procedures and techniques of nerve/space location that do not depend on the cooperation of the patient have been fully evaluated in children and should be routinely used in pediatric anesthesia.

Chronic activation of skeletal muscle is used clinically in representative numbers for diaphragm pacing to restore breathing and for dynamic graciloplasty to achieve fecal continence. The 3 different stimulation techniques currently used for electrophrenic respiration (EPR) all apply high frequency powered implants. It was our goal to make these stimulation methods applicable for EPR by a battery-powered nerve stimulator that would maximize the patient's freedom of movement. Additionally, the system should allow the implementation of multichannel techniques and alternating stimulation of 2 skeletal muscles as a further improvement in graciloplasty. Generally, the developed implantable nerve stimulator can be used for simultaneous and alternating activation of 2 skeletal muscles. Stimulation of the motor nerve is achieved by either single channel or multichannel methods. Carousel stimulation and sequential stimulation can be used for graciloplasty as well as for EPR. For EPR we calculated an operating time of the implant battery of 4.1 years based on the clinically used stimulation parameters with carousel stimulation. The multichannel pulse generator is hermetically sealed in a titanium case sized 65 x 17 mm (diameter x height) and weighs 88 g.

Nerve blocks of the lower extremity are undertaken less often than blocks of the upper limb. Spinal and epidural techniques are more common approaches to regional anesthesia of the lower extremity. Contrary to neuraxial techniques, isolated nerve blocks do not cause hypotension, retain the ability to void, and allow earlier unassisted ambulation despite a longer duration of action. However, the ideal block for every clinical scenario is not known. A knowledge of anatomy and some imagination may add some new approaches to our armamentarium. This article describes several new approaches to lower extremity blockade developed at the University of Saskatchewan. Many have proven successful, whereas others will have more limited applications. In this review we wish to outline the parasacral sciatic nerve block, the nerve stimulator approach to the lateral femoral cutaneous nerve of the thigh, the transsartorial saphenous nerve block, and the intraoperative transcruciate injection for total knee arthroplasty. The strengths and limitations are discussed together with a discussion of the relevant clinical anatomy of each approach.

Summary An inexpensive, portable nerve stimulator is described which is easily constructed and may be used to enhance the ease and effectiveness of peripheral nerve blockade.

OBJECTIVEElectrical stimulation of peripheral nerve tissue has been shown to accelerate axonal regeneration. Yet existing methods of applying electrical stimulation to injured peripheral nerves have presented significant barriers to clinical translation. In this study, the authors examined the use of a novel implantable wireless nerve stimulator capable of simultaneously delivering therapeutic electrical stimulation of injured peripheral nerve tissue and providing postoperative serial assessment of functional recovery.METHODSFlexible wireless stimulators were fabricated and implanted into Lewis rats. Thin-film implants were used to deliver brief electrical stimulation (1 hour, 20 Hz) to sciatic nerves after nerve crush or nerve transection-and-repair injuries.RESULTSElectrical stimulation of injured nerves via implanted wireless stimulators significantly improved functional recovery. Brief electrical stimulation was observed to increase the rate of functional recovery after both nerve crush and nerve tran...

Background and Objectives Recently it has been demonstrated that the use of ultrasound (US) improves the onset time and the quality of sensory block for 3-in-1 blocks compared with conventional nerve stimulator (NS) techniques. The present study was designed to evaluate if US guidance for 3-in-1 blocks reduces the amount of local anesthetic compared to NS guidance. Methods After institutional approval and informed consent, 60 patients undergoing hip surgery following trauma were randomly assigned to three groups of 20 patients each. In group A, the 3-in-1 block was performed using US guidance with 20 mL 0.5% bupivacaine. Group B received 20 mL 0.5% bupivacaine, and group C received 30 mL 0.5% bupivacaine during NS guidance. The quality and the onset time was assessed by pinprick test in the central sensory region of each of the three targeted nerves and compared with the contralateral leg every 10 minutes for 1 hour by a blinded observer. The rating was undertaken using a scale from 100% (uncompromised sensibility) to 0% (no sensation). Results Overall success for the 3-in-1 block in group A was 95% and in groups B and C 80%. Onset time was significantly shorter in the US-guided group compared with both NS-guided groups (group A 13 ± 6 minutes; group B 27 ± 12 minutes; and group C 26 ± 13 minutes; P Conclusion The amount of local anesthetic for 3-in-1 blocks can be reduced by using US guidance compared with the conventional NS-guided technique.

A short cut review was carried out to establish whether ultrasound placement of three-in-one block is better than placement using a nerve stimulator. 137 papers were found, of which two presented the best evidence to answer the clinical question. The author, date and country of publication, patient group studied, study type, relevant outcomes, results and study weaknesses of these best papers are tabulated. The clinical bottom line is that ultrasound guidance is better than electrical nerve stimulation at obtaining a good quality three in one femoral block.

Shock-wave lithotripsy is commonly employed for the treatment of nephrolithiasis in the pediatric patient population. This report describes such treatment of a patient with electronic nerve stimulators that were located in close proximity to bilateral renal pelvic stones. Precautions and considerations of shock-wave lithotripsy in this context are discussed.

Axillary brachial plexus blockade is a well established means of providing anesthesia and postoperative analgesia for upper extremity surgery. This article describes a technique using a bullet-tipped catheter-over-the-needle device for axillary brachial plexus blockade. This technique has several advantages over other techniques commonly used, including a very distinct endpoint when entering the brachial plexus sheath, a decreased risk of vascular and neural trauma, an insulated needle that confirms entry into the brachial plexus sheath using a nerve stimulator, a more proximal delivery site attributable to the 6.6 cm length of the catheter, and a ready means for providing continous anesthesia for prolonged procedures or postoperative analgesia. In conclusion, this method provides a safe, effective and versatile approach to axillary brachial plexus anesthesia.

This study set out to examine the nerve stimulators available in one trust hospital. Six different models were identified (Braun Stimuplex, Braun Stimuplex DIG, Digistim 3, Digistim 3 Plus, Regional Master Corporation Nerve Finder, Bard 750 Digital) and the output characteristics were measured for each stimulator using a twin beam calibrated storage oscilloscope. Target current output values from 0.3 mA to 3 mA and load resistances from 560 omega to 10k omega were selected to model the normal ranges of operating current and skin electrode-needle impedance when performing regional anaesthesia. Only half of the stimulators tested were able to complete the test and deliver a target current to +/-20% accuracy. The variation in performance of nerve stimulators means that for a safe and successful nerve block it is important for the operator to be aware of the design and functional limitations of any stimulator being used in clinical practice.

A 44-year-old female with a facial nerve neurinoma extending to the middle cranial fossa is described. The symptoms of the patient included tinnitus and hearing loss on the affected side, with no history of facial palsy. The pathological diagnosis was made following a biopsy of the tumor obtained from behind the tympanic membrane under exploratory tympanotomy.A middle cranial fossa approach and middle ear surgery were required to remove the tumor, and facial nerve decompression was performed after removal of the tumor. Intraoperative findings revealed that the tumor, which originated from the vertical to the pyramidal portions of the facial nerve, occupied the aditus and the posterior half of the epitympanum and the mesotympanum. Destruction of the tegmen of the epitympanum was evident, and the tumor was adherent to the dura of the middle cranial fossa.The tumor was removed intracapsularly with preservation of the facial nerve, continuity of the nerve fiber was confirmed using nerve stimulator. Facial palsy which was severe on the left side after the surgery, but gradually improved to become partial paralysis until now. Subsequent CT scans and MRI have revealed no signs of recurrence, and symptoms of recurrence of the tumor are also absent at present.

Previously, the hypoglossal nerve has not undergone intra-operative monitoring during neck operations in which the nerve is at risk. As society becomes increasingly litigious, this may change. This study describes the technique and the microvoltages used in 10 patients for intra-operative stimulation of the hypoglossal nerve with the Magstim nerve stimulator. We confirm that the technique is possible, simple and safe, with minimal disturbance to the patient, anaesthetist and surgeon.

Injecting local anesthetic at the seeking current would be appealing.It would save time and avoid potentially dangerous manipulations of the needle. This study aimed to test the hypotheses that in vertical infraclavicular block, injecting local anesthetic at a seeking current of 0.8 mA would produce the same quality of block as injecting at ≤0.5mA. A total of sixty ASA I -III adult patients scheduled for elective surgery on the hand, wrist and forearm in two equal groups of 30 patients, were enrolled in this study. The technique described by Kilka & Geiger used in both groups. After eliciting a clear and visible motor response of all fingers in either extension or flexion, injection was performed at a current of 0.8 mA and ≤0.5 mA in study and control groups respectively. Duration of time to analgesia and to anesthesia was evaluated. The mean duration of onset of analgesia in radial, median and ulnar nerves in both groups, were similar. The onset of anesthesia took a mean of 13.5 minutes in the control group and 15.6 minutes in study group (P=0.064). The onset of analgesia was 4.2 minutes in the control group and 4.3 minutes in study group. (P=0.508). The success rate in both groups was 100%. We had patients in both groups who developed complete anesthesia of the hand within 25 minutes. We conclude that the injection at 0.8 mA would result in a similar quality of block to one injected at ≤0.5 mA. The difference between two groups was not statistically significant.

BACKGROUND AND OBJECTIVES: Postoperative analgesia is crucial for early functional excise after total knee arthroplasty. To investigate the clinical efficacy of ultrasound and nerve stimulator guided continuous femoral nerve block analgesia after total knee arthroplasty. METHODS: 46 patients with ASA grade I-III who underwent total knee arthroplasty received postoperative analgesia from October 2012 to January 2013. In 22 patients, ultrasound and nerve stimulator guided continuous femoral nerve block were performed for analgesia (CFNB group); in 24 patients, epidural analgesia was done (PCEA group). The analgesic effects, side effects, articular recovery and complications were compared between two groups. RESULTS: At 6 h and 12 h after surgery, the knee pain score (VAS score) during functional tests after active exercise and after passive excise in CFNB were significantly reduced when compared with PCEA group. The amount of parecoxib used in CFNB patients was significantly reduced when compared with PCEA group. At 48 h after surgery, the muscle strength grade in CFNB group was significantly higher, and the time to ambulatory activity was shorter than those in PCEA group. The incidence of nausea and vomiting in CFNB patients was significantly reduced when compared with PCEA group. CONCLUSION: Ultrasound and nerve stimulator guided continuous femoral nerve block provide better analgesia at 6 h and 12 h, demonstrated by RVAS and PVAS. The amount of parecoxib also reduces, the incidence of nausea and vomiting decreased, the influence on muscle strength is compromised and patients can perform ambulatory activity under this condition. JUSTIFICATIVA E OBJETIVOS: Analgesia pós-operatória é fundamental para o exercício funcional precoce logo após a artroplastia total de joelho. O objetivo foi investigar a eficácia clínica do bloqueio contínuo do nervo femoral guiado por ultrassom e estimulador de nervo em analgesia após artroplastia total do joelho. MÉTODOS: Receberam analgesia pós-operatória, de outubro de 2012 a janeiro de 2013, 46 pacientes, estado físico ASA I-III, submetidos à artroplastia total de joelho. Em 22 pacientes, o bloqueio femoral contínuo foi guiado por ultrassom e estimulador de nervo para analgesia (grupo BFC); em 24 pacientes, analgesia foi administrada por via epidural (grupo ACP). Os efeitos analgésicos, efeitos colaterais, a recuperação articular e as complicações foram comparados entre os dois grupos. RESULTADOS: Às seis e 12 horas após a cirurgia, os escores de dor no joelho (escore EVA) durante os testes funcionais após exercício ativo e passivo foram significativamente menores no grupo BFC do que no grupo ACP. A quantidade usada de parecoxib nos pacientes do grupo BFC foi significativamente menor em comparação com o grupo ACP. Quarenta e oito horas após a cirurgia, o grau de força muscular no grupo BFC foi significativamente maior e o tempo de atividade ambulatória foi menor do que no grupo ACP. A incidência de náusea e vômito em pacientes do grupo BFC foi significativamente menor em comparação com o grupo ACP. CONCLUSÃO: O bloqueio femoral contínuo guiado por ultrassom e estimulador do nervo proporcionou melhor analgesia às seis e 12 horas, demonstrada por EVA-R e EVA-P. A quantidade de parecoxib também foi menor, a incidência de náusea e vômito diminuiu, a influência sobre a força muscular é comprometida e os pacientes podem fazer atividade ambulatorial sob essa condição. JUSTIFICACIÓN Y OBJETIVOS: La analgesia postoperatoria es fundamental para el ejercicio funcional precoz posteriormente a la artroplastia total de rodilla. El objetivo fue investigar la eficacia clínica del bloqueo continuo del nervio femoral guiado por ultrasonido y estimulador de nervio en analgesia después de la artroplastia total de la rodilla. MÉTODOS: Cuarenta y seis pacientes, con estado físico ASA I-III, sometidos a artroplastia total de rodilla recibieron analgesia postoperatoria de octubre de 2012 a enero de 2013. En 22 pacientes, el bloqueo femoral continuo fue guiado por ultrasonido y estimulador de nervio para analgesia (grupo BFC); en 24 pacientes, la analgesia fue administrada por vía epidural (grupo ACP). Los efectos analgésicos, efectos colaterales, recuperación articular y las complicaciones fueron comparados entre los 2 grupos. RESULTADOS: A las 6 y 12 h después de la operación, las puntuaciones de dolor en la rodilla (puntuación EVA) durante los test funcionales después del ejercicio activo y pasivo fueron significativamente menores en el grupo BFC que en el grupo ACP. La cantidad usada de parecoxib en los pacientes del grupo BFC fue significativamente menor en comparación con el grupo ACP. Cuarenta y ocho horas después de la operación, el grado de fuerza muscular en el grupo BFC fue significativamente mayor y el tiempo de actividad ambulatoria fue menor que en el grupo ACP. La incidencia de náuseas y vómitos en pacientes del grupo BFC fue significativamente menor en comparación con el grupo ACP. CONCLUSIÓN: El bloqueo femoral continuo guiado por ultrasonido y estimulador del nervio proporcionaron una mejor analgesia a las 6 y 12 horas, lo que quedó demostrado por EVA-R y EVA-P. La cantidad de parecoxib también fue menor, la incidencia de náuseas y vómito disminuyó, la influencia sobre la fuerza muscular está comprometida y los pacientes pueden realizar una actividad ambulatoria bajo esa condición.

Monitoring the level of neuromuscular blockade (NMB) throughout surgery is critical in ensuring patient safety, especially in preparing for extubation. Premature extubation is a life-threatening complication that results in expensive stays in the intensive care unit. Anesthesiologists need an inexpensive, practical device that works with their existing systems to objectively determine the appropriate time to extubate patients. Currently, the products on the market consist of two interfaced components: nerve stimulator and muscle response sensor. As many anesthesiologists already have a nerve stimulator the purchase of current products renders their existing stimulators useless. The mission of AcceleroMetrix is to develop an independent muscle response sensor that works with existing nerve stimulators to accurately measures NMB without receiving input from the nerve stimulator.

Muscle stimulation of the perineum is a crucial step in the repair of anorectal malformations. This allows the surgeon to assess muscle function and locate precisely the sphincter muscles during a pull-through operation. Presently, the device commonly used is very expensive. In searching for a cheaper and amenable device we explored utilizing the nerve stimulator MiniStim (model MS-IIIA, Life-Tech, Inc., Houston, TX) normally used for the "train of four" sign in assessing paralysis during general anesthesia. We have used this device in seven consecutive posterior sagittal anorectoplasties and compared its effectiveness with the regular muscle stimulator. In our experience, the nerve stimulator is easier to work with and is a common device in the operating theater. It gave us information that was at least equal to the regular muscle stimulator.

Objective:Clinicians hesitate to perform thoracic paravertebral blockade (TPVB) in children due to the potential high risk of adverse effects. No paediatric anatomical guidelines for TPVB exist. This study aimed to estimate the appropriate depth and distance for safe needle positioning in children.Methods:The depth (D) from the skin to the paravertebral space and the distance (A) from the spinous process to the needle entry point on the skin were measured using chest computed tomography (CT) in children aged between 1 and 9 years. Correlations between age, gender, weight, height, body mass index (BMI) and each of the anatomical measurements were analysed.Results:Each measurement correlated significantly with age, weight and height, but not with BMI (n = 373 children). Measurements A and D could be calculated by: A = 13.56 + (0.33 × age [years]) + (0.06 × weight [kg]) + 0.47 × (gender [female = 0, male = 1]); and D = 17.49 - (0.35 × age [years]) + (0.55 × weight [kg]).Conclusion:These anatomical guidelines for TPVB are recommended to help prevent anaesthetic complications such as pneumothorax, when ultra -sonography and CT are unavailable.

Physiotherapists use transcutaneous electrical nerve stimulation (TENS) to treat patients with chronic pain. This study reviewed the outcome at 6months of 71 patients who, following trial use, had indicated their intention to purchase a TENS machine. The majority of patients who had purchased machines continued to derive pain relief and functional benefit from their use. Certain distinctive patterns of use emerged among this group.

Background: Social media have been used to study many aspects of health and human behavior. Although social media present a unique opportunity to obtain unsolicited patient-reported outcomes, its use has been limited in plastic and reconstructive surgical procedures, including migraine nerve surgery. The goal of this study was to utilize the most popular social media site, Facebook, to evaluate patients’ experience with migraine surgery. Methods: Six months of data regarding nerve surgery, nerve stimulators, and radiofrequency nerve ablation were collected from posts and comments written by members of 2 Facebook groups. Outcomes were classified by degree of resolution of symptoms. Results: A total of 639 posts related to migraine surgery. Of 304 posts commenting on postoperative success of nerve surgery, 16% reported elimination of headaches and 65% significant improvement (81% with complete or significant improvement), 5% partial improvement, 11% no change, and 3% worsening symptoms. Nerve surgery had a higher success rate than nerve stimulators and radiofrequency ablation. Nerve surgery was recommended by 90% of users. Conclusions: The 81% rate of complete or significant improvement of symptoms in this study is close to the 79% to 84% shown in current literature. Similar to the findings of a recent systematic review, surgery is more efficacious compared with nerve stimulators and ablation. This study adds to evidence favoring migraine surgery by removing evaluator bias and demonstrates that surgical outcomes and satisfaction data may be obtained from social media.

Transcutaneous electrical nerve stimulation is a method of applying controlled, low-voltage electricity to the body in order to relieve pain. This technique is used in physiotherapy, in particular with patients who have chronic pain. An audit of the outcomes of a home-loan programme was undertaken to ascertain the short-and medium-term benefits of this treatment.

Electroanalgesia has been practised since ancient times, but had not gained widespread popularity with patients until the advent of transcutaneous electrical nerve stimulators in the 1970s. These electrical stimulator units have now been developed into highly effective relievers of pain, offering significant long term benefit to around 40% of chronic pain sufferers. A number of variations to the units have been designed to improve the efficacy of stimulation, however there remain 3 basic forms: continuous, pulsed and acupuncture-like. Before rejecting the method as ineffective for any patient, it is important to have an adequate trial of treatment of at least a fortnight during which all forms of available stimulation are tried, with electrodes placed in a variety of positions on the skin for a minimum of an hour at a time. Failure is generally due to lack of perseverence or unrealistic expectations.

Spinal cord stimulation in ischemic pain conditions has proved to be an effective method of treatment for many patients. The indications are ischemic pain in the extremities from peripheral vascular disease and angina pectoris. The long-term results show that the response rate for ischemic pain is 70% to 90%, while the corresponding results for neuropathic pain average approximately 50% to 70%, which actually makes ischemic pain a very good indication for SCS. SCS system implantation is a safe and quick operation performed under local anesthesia and well tolerated by the patient. A total implant of the lead and the pulse-generator in one stage seldom takes more than 1 hour. High sterility and prophylactic antibiotics are prerequisites to avoid postoperative problems. In atherosclerosis, SCS should be regarded as a method supplementary to vascular surgery, to be used for symptom recurrence after treatment or when there are technical obstacles to reconstructive surgery. SCS has proven to be extremely effective for the relief of ischemic rest pain, which constitutes the most severe problem for these patients. Today it is estimated that more than 7000 implants for PVD have been done in Europe. In a prospective randomized study, Jivegård et al have shown that SCS is a limb-saving treatment. For angina pectoris, SCS by now has become a routine supplementary method to conventional medical and surgical treatment. The technique is clinically effective, and several studies have shown decreased myocardial ischemia and decreased anginal pain during treatment. It is probable that the use of SCS in refractory angina will increase considerably in the 1990s.

Background and Aims: The availability, ergonomics and economics prohibit the routine use of algometers in clinical practice and research by the anesthesiologists. A simple bedside technique of quantitative pain measurement would enable the routine use of algometry. We proposed to validate simple pain provocation using sphygmomanometer cuff and the electric stimulation of neuromuscular junction monitor (TOF-guard, Organon Teknika) to measure pain against a standardized laboratory pressure algometer. Material and Methods: Pain detection threshold (Pdt) and pain tolerance threshold (Ptt) were measured in forty healthy volunteers of both genders, using the above three techniques. All measurements were repeated three times. The co-efficient of inter-rater reliability (or consistency) between three independent measurements obtained from each of the techniques was determined by Cronbach′s co-efficient alpha (α C). The correlation between the mean Pdt and Ptt values recorded by standardized algometer and the sphygmomanometer technique and nerve stimulator technique was performed using Pearson Correlation. An r >0.5 and a two-tailed significance of 0.7) for the three techniques. There was a good correlation with r >0.65 (P < 0.001) between the measurements of standardized pressure algometer and the two techniques being tested as alternatives for algometer to measure pain. Conclusion: The sphygmomanometer cuff technique and electrical stimulation with the peripheral nerve stimulator to measure pain threshold and tolerance provide a simple, efficient, repeatable measure of pain intensity and can be used as suitable alternatives to standard algometers.

Background. The relative effect of a transcutaneous peroneal nerve stimulator (tPNS) and an ankle foot orthosis (AFO) on spatiotemporal, kinematic, and kinetic parameters of hemiparetic gait has not been well described. Objective. To compare the relative neuroprosthetic effect of a tPNS with the orthotic effect of an AFO using quantitative gait analysis (QGA). Design. In all, 12 stroke survivors underwent QGA under 3 device conditions: (1) no device (ND), (2) AFO, and (3) tPNS. A series of repeated-measures analyses of variance (rmANOVAs) were performed with dorsiflexion status (presence or absence of volitional dorsiflexion) as a covariate to compare selected spatiotemporal, kinematic, and kinetic parameters for each device condition. Post hoc pairwise comparisons and/or subset analysis by dorsiflexion status were performed for significant effect. Results. Stride length was improved with both the AFO ( P = .035) and the tPNS ( P = .029) relative to ND. Those with absent dorsiflexion had longer stride length with the tPNS relative to ND ( P = .034) and a higher walking velocity with a tPNS relative to the AFO ( P = .015). There was no device effect on dorsiflexion angle at initial contact; however, a significant Device × Dorsiflexion status interaction effect favored the AFO relative to ND ( P = .025) in those with dorsiflexion present. Conclusion. This study suggests that level of motor impairment may influence the relative effects of the tPNS and AFO devices in chronic hemiparetic gait; however, the small sample size limits generalizability. Future studies are necessary to determine if motor impairment level should be considered in the clinical prescription of these devices.