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Analgesia and Anaesthesia
Published in Ian Greaves, Keith Porter, Jeff Garner, Trauma Care Manual, 2021
Ian Greaves, Keith Porter, Jeff Garner
The intercostal nerves run in the intercostal groove on the inferior aspect of the rib. For optimum analgesia the nerve should be blocked proximal to the origin of the lateral branch (posterior to the midaxillary line).
Lateral Hernias
Published in Jeff Garner, Dominic Slade, Manual of Complex Abdominal Wall Reconstruction, 2020
The traditional nephrectomy flank scar typically incises over the 11th or 12th ribs from sacrospinalis forward to the end of the ribs dividing the serratus posterior, latissimus dorsi and all three lateral abdominal wall muscles to access the retroperitoneum. The intercostal nerves run along the lower border of the ribs and branches continue anteriorly towards the umbilicus providing motor and sensory innervation. They may be injured by direct division during surgery or pressure from retraction (neuropraxia) with a rate of permanent flank bulge reported of up to 49%.18 A Swedish study of 197 successive open partial nephrectomy patients followed up for 2 years saw an initial bulge rate of 23% at 3 months decline to 2.7% at 24 months, whereas the clinical hernia rate increased from 0.6% to 4.9% over the same period19 suggesting that some of the initial clinical and radiological bulges seen were due to neuropraxia which subsequently resolved. As surgical technique has evolved, mini-incision nephrectomy utilising muscle splitting rather than division has further reduced the incisional hernia (IH) rate to 1.4%.20 Given the location of the incision, some may present intercostally, as may port site hernias from laparoscopic nephrectomy (Figure 15.15).
Blocks of Nerves of the Trunk
Published in Bernard J. Dalens, Jean-Pierre Monnet, Yves Harmand, Pediatric Regional Anesthesia, 2019
Intercostal nerve blocks may be recommended for improving the respiratory status of patients, either after a thoracotomy or in those with fractured ribs.1,36 However, they may produce severe impairment of breathing, mainly in patients with previous respiratory disease or after open-heart surgery.11,37–39 In normal patients, the latter complication may result from the spread of local anesthetics, paralysis of respiratory muscles (bilateral blocks), and/or depression of cough reflexes (with subsequent sputum retention).
Advantages and feasibility of intercostal nerve block in uniportal video-assisted thoracoscopic surgery (VATS)
Published in Postgraduate Medicine, 2023
The 4th or 5th intercostal space is used as the surgical incision site in uniportal VATS in clinical practice. Intraoperative injury to the intercostal nerve may lead to postoperative pain. The intercostal nerve is a mixed nerve branch formed by the union of the anterior and posterior roots after the thoracic spinal cord. Each intercostal nerve emerges from the intervertebral foramen and travels at the lower edge of the rib angle to the costal groove accompanying the intercostal artery. The pain felt by the nerve endings travels from the intercostal nerve to the nerve roots, spinal cord, and cerebral cortex. Therefore, ICNB is performed primarily from the rib angle. In addition, the adjacent intercostal skin is innervated by the intercostal nerve; therefore, the surrounding skin should also be blocked. Various regional analgesic techniques have been used to improve postoperative pain management in VATS and promote the normalization of the concept of rapid recovery [23,24].
“Undercutting of the corresponding rib”: a novel technique of increasing the length of donor in intercostal to musculocutaneous nerve transfer in brachial plexus injury
Published in British Journal of Neurosurgery, 2023
Kuntal Kanti Das, Jeena Joseph, Jaskaran Singh Gosal, Deepak Khatri, Pawan Verma, Awadhesh K Jaiswal, Arun K Srivastava, Sanjay Behari
Intercoastal nerves are frequently used for neurotization procedures in brachial plexus injuries. Due to a number of concerns, the upper intercostal nerves T3-T5 are favored as donors. The upper intercostal nerves (T3-T6) run parallel to the corresponding ribs in between the middle and the innermost intercostal muscles. For musculocutaneous nerve neurotization, ICNS 3rd to 5th are used as these 3 nerves combined not only provide a perfect size match but also the requisite number of motor axon available in these otherwise mixed nerves.6,7 The intercostal nerves are harvested starting proximally from the anterior axillary line, from the point of origin of serratus anterior muscle digitations to the costochondral junction distally. The general recommendation is to dissect as distally as possible to have a long donor nerve. However, the ICN becomes thinner as it moves towards the midline, with most of the motor branches leaving the nerve to supply the muscles. More proximally, the ICN remains hidden beneath the rib in the costal groove, which is itself covered by serratus anterior digitations. This anatomical fact was utilized by us and undercutting of the rib provided us with a few extra centimeters of ICN to obtain a tensionless co-aptation of ICN-MCN (Figure 3(B)).
Optimization of pleural multisite anesthetic technique during CT-guide microwave ablation of peripheral lung malignancy for improving treatment tolerance
Published in International Journal of Hyperthermia, 2022
Hao Hu, Fulei Gao, Jinhe Guo, Gaojun Teng, Zhi Wang, Bo Zhai, Rong Liu, Jiachang Chi
Percutaneous CT-guided transthoracic lung microwave ablation (MWA) is an established treatment technique for unresectable or medically inoperable lung malignancies. It provides a promising local tumor control rate and a good safety profile, and has the advantages of being minimally invasive, having only mildly deleterious effects on pulmonary function, needing only a short convalescence, and allowing repeated procedures [1–5]. Pain experienced by patients during thermal ablation of lung cancer is an important concern [6,7]. If intravenous anesthesia or analgesic drugs were not accepted during the procedure, intraoperative pain may oblige operators to alter the ablation algorithm (e.g., decrease microwave power and ablation time) to reduce pain. Such altered algorithms may affect the ablation zone and, ultimately, local efficacy. Intraprocedural pain can be more prominent when treating tumors located close to the pleura [8]. The parietal pleura and chest wall are sensitive to pain because abundant sensory nerve branches originate from the intercostal nerve, contrary to the case in the visceral pleura and lung parenchyma.