Background: Neurolymphomatosis is a process of neoplastic endoneurial invasion, most strongly associated with non-Hodgkin’s lymphoma. It must be distinguished from paraneoplastic, metabolic, nutritional and treatment-related causes of neuropathy that are common in this patient population. Methods: This brief case series illustrates the protean manifestations of neurolymphomatosis of the brachial plexus, ranging from focal distal mononeuropathy to multifocal brachial plexopathy, either as the index manifestation of lymphoma or as a complication of relapsing disease. Results: Prominent asymmetry, pain and nodular involvement on neuroimaging may help distinguish neurolymphomatosis from paraneoplastic immune demyelinating radiculoneuropathy. MR neurography criteria for the diagnosis of neurolymphomatosis include hyperintensity on T2 and STIR sequences, focal and diffuse nerve enlargement with fascicular disorganization and gadolinium enhancement. No specific anatomical distribution within the brachial plexus has, however, been found to be characteristic. Fluorodeoxyglucose-positron emission tomography (FDG-PET) imaging is the imaging modality with the highest sensitivity for detection of nodal or extranodal spread in lymphoma. Conclusions: Brachial plexus neuropathy in neurolymphomatosis is highly protean in its distribution, semiology and relation to lymphoma staging. Dedicated MRI and PET-CT imaging are leading diagnostic modalities.

Summary

Background and objective: The addition of clonidine to local anaesthetics enhances pain relief after peripheral nerve block, but the site of action is unproven.

Methods: Seven healthy volunteers underwent three brachial block procedures using bupivacaine 0.25% 1 mg kg−1 + epinephrine 1 : 200 000 (=local analgesic) in a randomized, double-blind cross-over fashion: (a) control treatment: local analgesic with 0.9% sodium chloride solution for the block and an intramuscular injection of saline; (b) intramuscular treatment: local analgesic with 0.9% NaCl for block and an intramuscular injection of clonidine 2 μg kg−1 and (c) block treatment: local analgesic with clonidine 2 μg kg−1 for block and an intramuscular injection of saline.

Results: The onset and duration of complete blockade (sensory/motor/temperature) was evaluated in the four nerve regions of the hand and forearm. Additionally, sedation score, blood pressure, heart rate and plasma clonidine concentrations were determined. The median duration of complete sensory blockade was 270 min (range 0–600) for block treatment compared to 0 min (range 0–480) for intramuscular treatment (P < 0.05) and 0 min (range 0–180) for control treatment (P < 0.05). Motor and temperature blockade exhibited similar results. Administration of clonidine was associated with sedation and a decrease in heart rate and blood pressure independent of the route of administration. Plasma clonidine concentrations were lower for block compared to the intramuscular treatment.

Conclusions: The admixture of clonidine to bupivacaine plus epinephrine prolongs and enhances brachial plexus blockade. Lower clonidine plasma concentrations for block treatment strongly suggest a local effect.

Background and objective: Patients' perception of limb position during regional anaesthesia is frequently incorrect. The incidence and nature of this phenomenon has not yet been completely described. The aim of this prospective study was to assess phantom sensation in patients undergoing a brachial plexus block.

Methods: Axillary block was performed in 81 patients with the aid of a peripheral nerve stimulator. Immediately after the block, patients were allocated randomly to two groups (Group 1, n = 40; Group 2, n = 41) to have the blocked limb placed either on their thorax or in abduction. Fifteen minutes later, when the block was complete, the position of the limb was changed, without the knowledge of the patient, to a new position of abduction and flexion of the forearm. Patients were questioned about the new limb position. Fifteen minutes later, the limb was then transiently shown to the patient and further placed ‘blindly’ to another position. Patients were once more questioned about this new position.

Results: Correct perception was more frequently observed in both groups following the first interview. Thirty-two and 34 patients gave at least one erroneous response about their limb position when it was initially placed on the thorax or in abduction respectively. Transient visualization of the limb position did not improve the rate of correct response.

Conclusions: Patients' perception of the position of the limb after axillary block in the majority of instances was probably due to persisting sensory inputs from the shoulder joint, which is not involved in this block. This in contrast to supraclavicular or interscalene blocks. A significant number of patients experienced phantom limb sensation. They reported an arm position in fact related to the position of their arm before the axillary block.

Background and objective Patients with end-stage chronic renal failure are at risk of developing several serious postanaesthetic complications. Many anaes-thesiologists perform brachial plexus anaesthesia with high doses of local anaesthetic in order to achieve an extensive blockade of the upper limb. Brachial plexus block is a suitable technique for anaesthesia for creation, repair or removal of vascular access for haemo-dialysis. The aim of this study was to measure mepivacaine plasma concentrations after axillary block with 650 mg plain mepivacaine in patients with end-stage chronic renal failure.

Methods Mepivacaine plasma concentrations were assessed throughout a 150-min period, in 10 patients after axillary block with 650 mg plain mepivacaine (600 mg for axillary block and 50 mg for supplementation).

Results Mepivacaine plasma concentrations expressed in μg mL−1 as medians and their ranges were: 1.69 (1.23–7.78) at 5min, 5.61 (4.36–8.19) at 30min, 8.28 (3.83–11.21) at 60min, 7.93 (5.63–11.1) at 90min and 6.49 (5.56–8.35) at 150 min without any symptoms of toxicity.

Conclusions Brachial plexus anaesthesia with 650 mg plain mepivacaine did not result in serious systemic toxicity in these patients despite the high mepivacaine plasma concentrations found.

Background and aim We evaluated the effect of the injection technique on the onset time and efficacy of interscalene brachial plexus anaesthesia.

Methods With Ethical Committee approval and written consent, 30 patients undergoing elective shoulder acromioplasty or capsuloplasty were randomly allocated to receive interscalene brachial plexus block with 20 mL of ropivacaine 0.75% by using either a single injection (Single group, n = 15) or multiple injection (Multiple group, n = 15). Nerve blocks were placed with the aid of a nerve stimulator using short bevelled, Teflon® coated needles. The stimulation frequency was set at 2 Hz and the intensity of stimulating current, initially set at 1 mA, was gradually decreased to ≤0.5 mA after each muscular twitch was observed. In the Single group, the anaesthetic solution was slowly injected after the first muscular twitch had been observed. In the Multiple group, 6mL were injected at shoulder abduction, 6mL were njected at arm flexion, and 6ml_ at the extension of the arm.

Results Placing the block required 5min (4–8 min) in the Multiple group and 3 min (1–10 min) in the Single group (P=0.001); however, total preoperative time (from skin disinfection to complete loss of pinprick sensation from C4 to C7 with inability to elevate the limb from the operating table) was shorter in the Multiple group (15 min; range 10–28 min) than in the Single group (23 min; range 14–60 min) (P=0.03). Additional intravenous fentanyl supplementation was required in two patients of the Multiple group (13%) and eight patients of the Single group (53%) (P=0.05).

Conclusion We conclude that using a multiple injection technique shortened the preparation time and improved the quality of interscalene brachial plexus anaesthesia performed with small volumes of ropivacaine 0.75%.

An acute pain service (APS) was set up to improve pain management after operation. We attempted to reduce the length of stay in the intensive care unit (ICU) of patients undergoing major surgery and to improve their homeostasis and rehabilitation using a multimodal approach (pain relief, stress reduction, early extubation). Patient-controlled epidural analgesia (PCEA) was a keystone of this approach. If PCEA was not applicable, patients received patient-controlled intravenous analgesia (PCIA) instead. Brachial plexus blockade (BPB) was used for surgery of the upper limbs. A computer based documentation system was used to help evaluate prospectively (a) the quality of analgesia, (b) adverse effects and risks of the special pain management techniques, and (c) cost-effectiveness.

Patients receiving PCEA (n = 5.602) received a patient-titrated continuous infusion into the epidural space of either bupivacaine 0.175% or ropivacaine 0.2%, with 1 μg sufentanil mL−1 added, followed by patient-controlled boluses of 2 mL (lockout time 20 min). For patients receiving PCIA (n = 634) an initial bolus of 7.5–15 mg piritramide was given, and the subsequent bolus was 2 mg (lockout time 10 min). A continuous infusion of bupivacaine 0.25% was administered to patients receiving BPB (n = 113). The dose was titrated to a dynamic visual analogue scale (VAS) scores < 40.

The mean treatment periods were: BPB = 4.33 days, PCEA = 5.6 days, PCIA = 5.0 days. In the case of PCEA, the quality of pain relief, vigilance and satisfaction were superior compared with the PCIA method, which resulted in greater sedation and nausea. Although personal supervision was higher for the PCEA-treated patients, cost analysis revealed final savings of €91 620 for the year 1998 obviating the need for an ICU stay totalling 433 days.

Provided that PCEA is part of a fast-track protocol employing early tracheal extubation and optimal perioperative management, the associated initial higher costs will be recouped by the benefits to patients of better pain relief after surgery and fewer days subsequently spent in the ITU.

Schwannomas are peripheral nerve tumours of nerve sheath origin. We report one case of cervical schwannoma originating from the brachial plexus. A 56-year-old man presented with a slow-growing mass on the right side of his neck that had been noted for more than 10 years. During operation, a wellencapsulated mass was seen beneath the brachial plexus with adhesion to the plexus element. It was reported as a schwannoma. Three days after surgery, the patient had a motor deficit of the right upper arm and neurological examination showed a CV nerve deficit. The neurological function recovered completely after three months. In addition, the other five cases of cervical schwannoma seen in our hospital between March 1990 and June 1998 are also reviewed. All patients had surgery. The pre-operative symptoms, impressions, and post-operative neurological status were shown and discussed. Only two cases were diagnosed as neurogenic tumour pre-operatively. Post-operatively, one patient had transient neurological deficit and another one had permanent deficit.

We describe the proximal cranial needle approach for brachial plexus blockade; clear surface markings and cranial direction of the needle lead to satisfactory results with a low incidence of complications.

We have assessed prospectively the time to readiness for surgery following axillary block (sum of block performance and latency times) in 80 patients. The brachial plexus was identified using a nerve stimulator, and anaesthetized with 45 mL of mepivacaine 1% with adrenaline 5 μgmL−1. In group 1 (single injection) the whole volume of mepivacaine was injected after locating only one of the plexus nerves. In group 2 (multiple injections) at least three plexus nerves were located, and the volume of mepivacaine was divided between them. Sensory block was assessed by a blinded observer every 10 min. Patchy analgesia was supplemented after electrolocating the unblocked nerves after 20, 30 or 40 min. The patient was pronounced ready for surgery when analgesia was present in all areas to be operated upon, which always included the three nerves to the hand. The single injection technique required less time for block performance (mean 5.5 min) than multiple injections (mean 9.5 min), P < 0.0001. However, latency of the block was longer and the requirement for supplemental nerve blocks was greater, after single injections (33 min and 57%) than after multiple injections (15.5 min and 7%, respectively), P < 0.0001. As a result, readiness for surgery was achieved faster in group 2 (25 min), than in group 1 (38.5 min), p < 0.0001. After supplementation, block effectiveness was 100% in group 1 and 98% in group 2 (NS). The frequency of adverse effects (vessel puncture or paraesthesia) was similar in both groups. No neurological sequelae were observed.We conclude that the multiple injection technique takes longer to perform than single injection, but that readiness for surgery is faster because of shorter block latency and better spread of analgesia.