الفهرس 
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Abstract
Regional anesthesia has more to offer in orthop: edic surgery
than in any other surgical speciality, either alone ( . as a part of
anesthetic consequence. If all regional techniques COl d be carried
out by a single injection, as is done with spinal ( id epidural
anesthesia, then most if not all of the objections to regional
anesthesia by surgeons, anesthesiologists, and patu 1tSwould be
overcome.
This study was conducted on 250 patients of ,SA physical
status I and II presenting for surgery of the upper ant lower limbs.
They were divided into two main groups A and B ac ording to the
site of block.
In group A. brachial plexus blocks were peri mned on 150
patients classified into 3 equal subgroups according to the chosen
technique and type of local anesthetic solution.
Subgroup AI: The brachial plexus was blocke I using the
parascalene technique. Each patient received 3m~ Kg of 0.5%
. bupivacaine with adrenaline 1:200,000.
. Subgroup All: The brachial plexus was block d using the
subclavian perivascular technique. Each patient rece ved 3 mg/Kg
of 0.5% bupivacaine with adrenaline 1:200,000.
Subgroup A1I1: The brachial plexus was block d using the
subclavian perivascular technique. Each patient rec ived 3mg/Kg
of pH adjusted bupivacaine 0.5% with adrenaline I :2( ),000.
Difficulty in provoking paresthesia was recc ’ded. Sensory
blockade was assessed by the pinprick test every or ~minute. The
time of onset and the time to peak sensory block’ ’ere recorded.
Duration of anesthesia and postoperative analge. .a were also
. recorded. Sensory testing was carried out in the are s supplied by
the following nerves: axillary, musculocutaneous, I idial, median,
ulnar, medial cutaneous of the forearm and medial CI .aneous nerve
of the arm.
After assessment of the onset of sensory bl ckade of each
cutaneous nerve of the brachial plexus, the intercostr irachial nerve
and the. medial cutaneous nerve of the arm we e blocked if
required. A failed block was one where there w: s no elicited
paresthesia or where the sensory blockade involved, rly a single or
none of the following nerves: median, ulru ’, radial or
musculocutaneous.
Motor block was assessed every one minute anc amplitude of
block was graded as: 0, no motor block; 1, inability :0 abduct the
shoulder or flex the elbow against resistance; 2 inab ity to abduct
the shoulder or flex the elbow against gravity; 3, inab ity to abduct
the shoulder or flex the elbow and wrist against gra ’ity. Onset of
motor blockade (grade 1) and time to peak motor bf ckade (grade
3) were recorded.
The patients were closely observed for signs anc symptoms of
systemic toxicity of local anesthetics and were als- observed for
symptoms and signs of pneumothorax, phrenic ~ id recurrent
laryngeal nerve paralyses. Routine X-ray was don four hours
postoperatively for each patient to assess the c .currance of
pneumothorax and/or phrenic nerve palsy.
There were no statistically significant differences ~ , regards age,
sex, weight and type of surgery between the 3 sub ;roups. In the
present work with the parascalene technique, pal :sthesia ’was
provoked easily in 62% of cases, after few attempts in 20% of cases
and after several attempts in 10% of cases. The su cess rate was
92%. With the subclavian perivascular technique, I irethesia was
provoked easily in 45% of cases, after few attempts ir 36% of cases
and after several attempts in 8% of cases. The su cess rate was
. 89%.
Using bupivacaine 0.5% with adrenaline 1:20 ,000 in the
. parascalene technique, the onset time of sensory bk ckade ranged
from 5 to 10 minutes with a mean of 5.8+0.8 min. Th time to peak
sensory block ranged from 15 to 25 minutes wit a mean of
19.1±2.2 min. Duration of anesthesia ranged from 135 to 240
minutes with a mean of 198.2 + 31.9 min. Postopen .ive analgesia
was 8.71 + 1.1 hour.
Administration of plain bupivacaine 0.5% v ith adrenaline
1:200,000 in the subclavian perivascular technique, he onset time
of sensory blockade ranged from 5 to 10 minutes’ lith a mean of
5.6 + I min. The time to peak sensory effect rangec from 15 to 25
. minutes with a mean of 18.5 + 2 minutes. Duratio of anesthesia
ranged from 135 to 270 minutes with a mean of2IC + 33 minutes.
Postoperative analgesia was 8.23 + 1.08 hour.
Using of bupivacaine with adrenaline 1:2 0,000 in the
parascalene technique, the onset time of motor b ockade ranged
from 6 to 12 minutes with a mean of 8.3 + 1.2 minui s. The time to
peak motor blockade ranged form 18 to 24 minute i with mean of
19.9 + Hi minutes. In the subclavian perivascular echnique, with
the use of plain bupivacaine, the onset time of iotor blockade
ranged from 6 to 12 minutes with a mean of 8 + 1.: min. The time
. to peak motor blockadge ranged from 17 to 23 minu es with a mean
of 19.2 + 1.8 min.
Using of pH-adjusted bupivacaine 0.5% wit I adrenaline
1:200,000, the onset time of sensory blockade range j from 4 to 7
minutes with a mean of 5 + 1 minutes. The time to peak sensory
blockade ranged from 13 to 22 minutes with a mean of 17.7 + 1.9
minutes. Duration of anesthesia ranged form 135 tc 270 minutes
with a mean of204 + 36 minutes. Postoperative analg :sia was 8.50
+ 1.43 hour.
In the present study, with the exception of the met ial cutaneous
nerve of the arm, both the parascalene and subclavia perivascular
techniques resulted in a homogenous blockade of al nerves of the
brachial plexus .
.No signs of symptoms or local anesthetic toxicity vas observed
in either subgroup.
One patient with a parascalene block became he irse. Horner’s
syndrome was developed in 32% and 15% of .ases in the
parascalene and subclavian perivascular techniques respectively.
There was one case of pneumothorax in the subclavia perivascular
technique.
Statistical analysis revealed that the success rate was the same
. for both the parascalene and subclavian perivascular t chniques but
paresthesia was provoked more easily with the parascalene
technique. With bupivacaine 0.5%, the block charac eristics were
identical for both techniques. With pH-adjusted bupi’ acaine 0.5%,
the onset of sensory and motor blockade was rapid :han with the
plain bupivacaine 0.5%. Duration of anesthesia and sostopertaive
analgesia were the same for both the plain and pH-adjusted
bupivacaine. With the exception of the medial cutar eous nerve of
the arm.. both techniques resulted in a homogenous 1 .ockade of all
nerves of the brachial plexus.
In group B, lumbar plexus blocks were per irmed on 100
patients presenting for diagnostic and operative art!”:oscopy of the
knee. Patients were allocated into two equal subgro ps BI and BII
according to the technique of lumbar plexus block.
Subgroup BI: The lumbar plexus was blocked usi g the inguinal
paravascular technique (3 in 1 block). Each patient eceived 35 ml
of 0.5% bupivacaine with adrenaline 1:200,001
• This was
combined with the lateral femoral cutaneous nerve t ock using 5ml
of 0.5% bupivacaine.
Subgroup Bll: The lumbar plexus was blocked u ing the lumbar
paravertebral approach. Each patient received 3 ml of 0.5%
bupivacaine with adrenaline 1:200,000.
Difficulty in provoking paresthesia was recorded. • failed block
was one where there was no elicited paresthesia.
Sensory blockade was assessed by the pin-prick est every one
minute. The time of onset and the time to peak sensi ry block were
recorded. Duration of anesthesia and postoperative; nalgesia were
also recorded. Sensory testing was carried out in the skin areas
supplied by the following nerves: femoral, obturai Ir and lateral
cutaneous nerve of the thigh.
Pain on surgical incision was recorded. Tln patients were
closely observed for signs and symptoms of syste nic toxicity of
local anesthetics.
The patients were also closely observed for tlu occurrance of
subarachnoid or epidural injection and for sym: athetic nerve
blockade.
There were no statistically significant differe Icesas regards
age, weight and sex distribution between the inguir II paravascular
and the lumbar paravertebral approaches. All pat ents are under
diagnostic knee artroscopy.
In the present study we had observed that parestl esia was easily
. provoked in 52% and 24% of the patients i the inguinal
paravascular and the lumbar paravertebral technique respectively.
The success rate was 90% and 64% for the inguina paravascular
. and the lumbar paravertebral blocks respectively.
70 patients had pneumatic tourniquet applied to t] e thigh, 42 in
subgroup BI and 28 in subgroup BII. None c mplained of
tourniquet pain.
Three patients in the inguinal paravascular subgroi ) experienced
pain on lateral knee incision and had supplemental h cal anesthetic
(l0 ml of 1% xylocaine) injected intraarticularly t r the surgeon,
and the procedure was completed.
. Studying of the sensory blockade characteristics, he onset time
was 9.37 + 1.4 min. and 8.35 + 1.43 min. for the twc subgroups BI
and BITrespectively. The time to peak sensory blocks le was 21.5 +
2.2 min. and 19.37 + 5.2 min. for the two subgro ps BI and BII
respectively. Duration of anesthesia was 195 + 33.7 r in. and 216 +
29.9 min. for the two subgroups BI and BII respectively.
Postoperative analgesia was 7.45 + 1.12 hour and 8. 5 + 1.98 hour
for the two subgroups BI and BITrespectively.
In both techniques, adequate anesthesia develop! in 20-25 min,
the time usually needed for preparation and drapi g of the knee.
The muscle relaxation produced with either regional echnique was
adequate, and both patients and surgeons were genei LIlysatisfied.
Both techniques produce adequate anesthesia for di gnostic knee
. arthroscopy, removal of plica, repair of meniscal teal and shaving
of cartilage.
No instance of central nervous system or cardiovas .ular toxicity
was observed in either subgroup. Also there was n( incidence of
subarachnoid or epidural injection.
Statistical analysis revealed that the SUCCI 5S rate was
significantly higher with the inguinal paravascular tc chnique than
with the lumbar paravertebral technique. Paresthesi . was easily
provoked with the first one. Blockade charateristics x ere the same
for both techniques, but the onset of sensory block de was rapid
with the lumbar paravertebral block.
In conclusion, the parascalene and subclaviai perivascular
techniques have proven to be useful, simple, safe an reliable. All
the operative procedures of the whole upper limb can Ieperformed
under either of both techniques. The use of3 mg/Kg 0 bupivacaine
in these techniques has been shown to be a safe and ef ective agent,
providing proper technique and precautions are fc lowed. The
addition of sodium bicarbonate to bupivacaine acceler tes the onset
of blockade.
The inguinal paravascular block of lumbar ple .us combined
with lateral femoral cutaneous nerve block provi les adequate
anesthesia for outpatient knee arthroscopy and is a gr )d alternative
to general and spinal anesthesia.