Sala‐Blanch, Xavier

ABSTRACT The microvasculature of peripheral nerve not only is important for the understanding of the development of compression syndromes, but it plays a critical role in the evolution of other nerve pathologies, including, for example, the distribution of intraneural ganglion cysts and lymphoma. We investigated the anatomical course of vessels around the human sciatic nerve and its bifurcation in eight human cadavers. Specifically, the presence of fenestrations on the epineurium and paraneurium's thickness in relation to the intraneural vessels was investigated. The sciatic, tibial, peroneal and sural nerves at the level of the bifurcation are surrounded by different layers, including the epineurium and paraneurial layers. Multiple fenestrations were observed in all membranes surrounding these nerves, which formed openings for the transfer of adipocytes and vessels from one compartment to the neighboring one. The openings were relatively large compared to the size of the vessels. In conclusion, vessels always travel through a natural opening in the paraneurial and epineurium. These vessels are important connections between the extrinsic and intrinsic nerve vasculature. In addition, the fenestration provides an important anatomical explanation for the possibility of transfer of anesthetic agents or different nerve pathologies, including intraneural ganglion cyst and tumors.

OBJECTIVE Extreme subparaneurial ganglion cysts are poorly understood. In Part 1, the authors demonstrated that patterns of distribution in the subparaneurial space are consistent with the principles of the articular theory for intraneural ganglion cysts (INGCs). How a cyst transfers from the subepineurial to the subparaneurial compartment remains to be determined. In this part, the authors provide evidence supporting that cyst transfer occurs at the sciatic nerve bifurcation based on MRI and histological analysis, and introduce the geyser theory as an explanation for the redistribution of cysts. METHODS The authors analyze MR images obtained in patients with extreme subparaneurial cysts as well as newly identified cases of nearly extreme subparaneurial cysts (i.e., cysts visible in the subparaneurial compartment but not to the extreme degree as defined in Part 1) for potential crossover sites. They also analyze histological sections from 10 cadavers around the sciatic nerve bifurcation for the presence of openings in the epineurium and paraneurium. RESULTS MRI studies performed in 8 patients in Part 1 and 8 newly identified examples with nearly extreme subparaneurial INGCs showed evidence to support communication between different compartments at the sciatic nerve bifurcation (subepineurial-to-subparaneurial and subparaneurial-to-neighboring soft tissues). Openings in the epineurium of the common peroneal and tibial nerves at the sciatic nerve bifurcation were consistently found in all 10 cadaver specimens, as were openings in the paraneurium. CONCLUSIONS The authors expand on the evidence to support cyst redistribution at the sciatic nerve bifurcation for INGCs in the knee region. They put forth a logical explanation for the development of a spectrum of extreme INGCs (ranging from a faint amount of cyst around the epineurium [wedding ring sign] to extreme subparaneurial INGCs [owl eyes]) based on principles seen in a geyser. The authors believe that radiological occurrence of crossover can be explained by the presence of fenestrations in both the epineurium and paraneurium at the sciatic nerve bifurcation, allowing cyst crossover in two steps: from the subepineurial to the subparaneurial space ("cross") and between a shared subparaneurial space of different nerves ("over"). Finally, the frequent occurrence of extraneural rupture ("cross-out") is due to cyst transfer into the soft tissue compartment via an opening in the outermost circumneurial layer.

Background The Midclavicle Block achieves balanced methylene blue spread across both anterosuperior and posteroinferior periosteal surfaces in cadavers with intact clavicles. Objective To evaluate the anatomical distribution pattern of the Midclavicle Block in cadaveric specimens with midshaft clavicle fractures, with a focus on periosteal coverage and involvement of the fracture site. Methods An anatomical study was conducted on 10 cadavers (20 clavicular regions). A midshaft clavicle fracture model was created, and the Midclavicle Block technique was applied under ultrasound guidance. A methylene blue solution was injected, and dissections were performed to evaluate dye spread primarily in the deep muscular and the clavicular plane, including the fracture site. Probabilistic maps of dye distribution were generated. Results The anatomical dissection in the deep muscular plane revealed consistent staining of the fracture site in all specimens, along with the subclavius muscle and the clavipectoral fascia, while the pectoralis minor muscle remained unaffected in every case. As the dissection progressed toward the infraclavicular brachial plexus plane, no staining of the plexus was observed, with dye spread restricted to the subclavius muscle and adjacent clavipectoral fascia. The mean staining of the anterosuperior and posteroinferior periosteal surfaces was 55.5% (95% CI: 50.6% to 60.4%) and 53.8% (95% CI: 49.5% to 58.1%), respectively. The highest dye concentration was observed in the middle third of the clavicle, corresponding to the fracture zone. Conclusion The Midclavicle Block resulted in effective periosteal coverage and targeted fracture site staining. Clinical studies are needed to confirm its in vivo efficacy, given the limitations inherent to cadaveric specimens.

Background Inconsistent nomenclature and anatomical descriptions of regional anesthetic techniques hinder scientific communication and engender confusion; this in turn has implications for research, education and clinical implementation of regional anesthesia. Having produced standardized nomenclature for abdominal wall, paraspinal and chest wall regional anesthetic techniques, we aimed to similarly do so for upper and lower limb peripheral nerve blocks. Methods We performed a three-round Delphi international consensus study to generate standardized names and anatomical descriptions of upper and lower limb regional anesthetic techniques. A long list of names and anatomical description of blocks of upper and lower extremities was produced by the members of the steering committee. Subsequently, two rounds of anonymized voting and commenting were followed by a third virtual round table to secure consensus for items that remained outstanding after the first and second rounds. As with previous methodology, strong consensus was defined as ≥75% agreement and weak consensus as 50%–74% agreement. Results A total of 94, 91 and 65 collaborators participated in the first, second and third rounds, respectively. We achieved strong consensus for 38 names and 33 anatomical descriptions, and weak consensus for five anatomical descriptions. We agreed on a template for naming peripheral nerve blocks based on the name of the nerve and the anatomical location of the blockade and identified several areas for future research. Conclusions We achieved consensus on nomenclature and anatomical descriptions of regional anesthetic techniques for upper and lower limb nerve blocks, and recommend using this framework in clinical and academic practice. This should improve research, teaching and learning of regional anesthesia to eventually improve patient care.

Background There is heterogeneity in the names and anatomical descriptions of regional anesthetic techniques. This may have adverse consequences on education, research, and implementation into clinical practice. We aimed to produce standardized nomenclature for abdominal wall, paraspinal, and chest wall regional anesthetic techniques. Methods We conducted an international consensus study involving experts using a three-round Delphi method to produce a list of names and corresponding descriptions of anatomical targets. After long-list formulation by a Steering Committee, the first and second rounds involved anonymous electronic voting and commenting, with the third round involving a virtual round table discussion aiming to achieve consensus on items that had yet to achieve it. Novel names were presented where required for anatomical clarity and harmonization. Strong consensus was defined as ≥75% agreement and weak consensus as 50% to 74% agreement. Results Sixty expert Collaborators participated in this study. After three rounds and clarification, harmonization, and introduction of novel nomenclature, strong consensus was achieved for the names of 16 block names and weak consensus for four names. For anatomical descriptions, strong consensus was achieved for 19 blocks and weak consensus was achieved for one approach. Several areas requiring further research were identified. Conclusions Harmonization and standardization of nomenclature may improve education, research, and ultimately patient care. We present the first international consensus on nomenclature and anatomical descriptions of blocks of the abdominal wall, chest wall, and paraspinal blocks. We recommend using the consensus results in academic and clinical practice.