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      The ultrasound-guided retrolaminar block: volume-dependent injectate distribution

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          Abstract

          Purpose

          The ultrasound-guided retrolaminar block is one of the newer and simpler alternatives to the traditional, often technically challenging, paravertebral (PV) block. Its feasibility, safety, and efficacy have already been clinically demonstrated in patients with multiple rib fractures using higher volumes of local anesthetic, when compared with the traditional approach. The primary aim of this observational anatomical study was to assess the spread of local anesthetic from the retrolaminar injection point to the PV space and its volume dependence. Second, we assessed the incidence of epidural and contralateral PV spread in the both groups.

          Methods

          Ten fresh porcine cadavers were randomized into 2 groups (n=5 each) to receive ultrasound-guided retrolaminar injections at Th4-Th5 level with either 10 mL (low-volume group) or 30 mL (high-volume group) of 2% lidocaine and methylene blue mixture. After the procedure, the cadavers were dissected and frozen. Cross-section cuts (~1 cm thick) were performed to evaluate the injectate spread.

          Results

          In the high-volume group, injectate spread from the retrolaminar to the PV space was observed in all specimens (5 out of 5; 100%), while in the low-volume group, no apparent spread to the PV space was found (0 out of 5; 0%). No epidural or contralateral PV spread was observed in any of the specimens.

          Conclusion

          Following ultrasound-guided retrolaminar injections in fresh porcine cadavers, injectate spread from the retrolaminar tissue plane to the PV space is strongly volume dependent, suggesting that, clinically, high local anesthetic volumes maybe critical for achieving regional anesthesia and analgesia consistent with traditional PV blockade.

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          Most cited references 24

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          Rib fractures in the elderly.

          We sought to ascertain the extent to which advanced age influences the morbidity and mortality after rib fractures (fxs), to define the relationship between number of rib fractures and morbidity and mortality, and to evaluate the influence of analgesic technique on outcome. A retrospective cohort study involving all 277 patients > or = 65 years old with rib fxs admitted to a Level I trauma center over 10 years was undertaken. The control group consisted of 187 randomly selected patients, 18 to 64 years old, with rib fxs admitted over the same time period. Outcomes included pulmonary complications, number of ventilator days, length of intensive care unit and hospital stay (LOS), disposition, and mortality. The specific analgesic technique used was also examined. The two groups had similar mean number of rib fxs (3.6 elderly vs. 4.0 young), mean chest Abbreviated Injury Scores (3.0 vs. 3.0), and mean Injury Severity Score (20.7 vs. 21.4). However, mean number of ventilator days (4.3 vs. 3.1), intensive care unit days (6.1 vs. 4.0), and LOS (15.4 vs. 10.7 days) were longer for the elderly patients. Pneumonia occurred in 31% of elderly versus 17% of young (p 2 days) was associated with a 10% mortality versus 16% without the use of an epidural (p = 0.28). In the younger group (LOS >2 days), mortality with and without the use of an epidural was 0% and 5%, respectively. Elderly patients who sustain blunt chest trauma with rib fxs have twice the mortality and thoracic morbidity of younger patients with similar injuries. For each additional rib fracture in the elderly, mortality increases by 19% and the risk of pneumonia by 27%. As the number of rib fractures increases, there is a significant increase in morbidity and mortality in both groups, but with different patterns for each group. Further prospective study is needed to determine the utility of epidural analgesia in this population.
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            Comparative anatomical dimensions of the complete human and porcine spine

            New spinal implants and surgical procedures are often tested pre-clinically on human cadaver spines. However, the availability of fresh frozen human cadaver material is very limited and alternative animal spines are more easily available in all desired age groups, and have more uniform geometrical and biomechanical properties. The porcine spine is said to be the most representative model for the human spine but a complete anatomical comparison is lacking. The goal of this descriptive study was to compare the anatomical dimensions of the cervical, thoracic, and lumbar vertebrae of the human and porcine spine in order to determine whether the porcine spine can be a representative model for the human spine. CT scans were made of 6 human and 6 porcine spines, and 16 anatomical dimensions were measured per individual vertebrae. Comparisons were made for the absolute values of the dimensions, for the patterns of the dimensions within four spinal regions, and normalised values of the dimensions within each individual vertebra. Similarities were found in vertebral body height, shape of the end-plates, shape of the spinal canal, and pedicle size. Furthermore, regional trends were comparable for all dimensions, except for spinal canal depth and spinous processus angle. The size of the end-plates increased more caudally in the human spine. Relating the dimensions to the size of the vertebral body, similarities were found in the size of the spinal canal, the transverse processus length, and size of the pedicles. Taking scaling differences into account, it is believed that the porcine spine can be a representative anatomical model for the human spine in specific research questions.
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              Anatomy of large animal spines and its comparison to the human spine: a systematic review.

              Animal models have been commonly used for in vivo and in vitro spinal research. However, the extent to which animal models resemble the human spine has not been well known. We conducted a systematic review to compare the morphometric features of vertebrae between human and animal species, so as to give some suggestions on how to choose an appropriate animal model in spine research. A literature search of all English language peer-reviewed publications was conducted using PubMed, OVID, Springer and Elsevier (Science Direct) for the years 1980-2008. Two reviewers extracted data on the anatomy of large animal spines from the identified articles. Each anatomical study of animals had to include at least three vertebral levels. The anatomical data from all animal studies were compared with the existing data of the human spine in the literature. Of the papers retrieved, seven were included in the review. The animals in the studies involved baboon, sheep, porcine, calf and deer. Distinct anatomical differences of vertebrae were found between the human and each large animal spine. In cervical region, spines of the baboon and human are more similar as compared to other animals. In thoracic and lumbar regions, the mean pedicle height of all animals was greater than the human pedicles. There was similar mean pedicle width between animal and the human specimens, except in thoracic segments of sheep. The human spinal canal was wider and deeper in the anteroposterior plane than any of the animals. The mean human vertebral body width and depth were greater than that of the animals except in upper thoracic segments of the deer. However, the mean vertebral body height was lower than that of all animals. This paper provides a comprehensive review to compare vertebrae geometries of experimental animal models to the human vertebrae, and will help for choosing animal model in vivo and in vitro spine research. When the animal selected for spine research, the structural similarities and differences found in the animal studies must be kept in mind.
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                Author and article information

                Journal
                J Pain Res
                J Pain Res
                Journal of Pain Research
                Journal of Pain Research
                Dove Medical Press
                1178-7090
                2018
                07 February 2018
                : 11
                : 293-299
                Affiliations
                [1 ]Clinical Department of Anesthesiology and Intensive Therapy, University Medical Centre Ljubljana, Ljubljana, Slovenia
                [2 ]Institute of Anatomy, Faculty of Medicine, University of Ljubljana, Ljubljana, Slovenia
                [3 ]Department of Anesthesiology, Perioperative and Pain Medicine, Brigham and Women’s Hospital, Harvard Medical School, Boston, MA, USA
                Author notes
                Correspondence: Marija Damjanovska, Clinical Department of Anesthesiology and Intensive Therapy, University Medical Centre Ljubljana, Zaloska 7, 1000 Ljubljana, Slovenia, Tel +386 41 990 745, Email marijadamjanovska@ 123456gmail.com
                Article
                jpr-11-293
                10.2147/JPR.S153660
                5808708
                © 2018 Damjanovska et al. This work is published and licensed by Dove Medical Press Limited

                The full terms of this license are available at https://www.dovepress.com/terms.php and incorporate the Creative Commons Attribution – Non Commercial (unported, v3.0) License ( http://creativecommons.org/licenses/by-nc/3.0/). By accessing the work you hereby accept the Terms. Non-commercial uses of the work are permitted without any further permission from Dove Medical Press Limited, provided the work is properly attributed.

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                Original Research

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