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•There is some contention regarding paravertebral spread after ESP block.•Costotransverse notch (CTN) is formed by the transverse process and rib.•Injection at the CTN can easily achieve paravertebral spread.•The site of CTN injection is close to that of the MTP block.

Using a linear discriminant analysis of heart rate variability (HRV) indices, the present study sought to verify the usefulness of autonomic measurement in major depressive disorder (MDD) patients by assessing the feasibility of their return to work after sick leave. When reinstatement was scheduled, patients’ HRV was measured using a wearable electrocardiogram device. The outcome of the reinstatement was evaluated at one month after returning to work. HRV indices including high- and low-frequency components were calculated in three conditions within a session: initial rest, mental task, and rest after task. A linear discriminant function was made using the HRV indices of 30 MDD patients from our previous study to effectively discriminate the successful reinstatement from the unsuccessful reinstatement; this was then tested on 52 patients who participated in the present study. The discriminant function showed that the sensitivity and specificity in discriminating successful from unsuccessful returns were 95.8% and 35.7%, respectively. Sensitivity is high, indicating that normal HRV is required for a successful return, and that the discriminant analysis of HRV indices is useful for return-to-work screening in MDD patients. On the other hand, specificity is low, suggesting that other factors may also affect the outcome of reinstatement.

Local anesthetic injection into the medial head of the semispinalis capitis muscle can anesthetize the greater occipital nerve (GON) and third occipital nerve (TON) simultaneously (greater and third occipital nerve block: GTO block). Alternatively, inter-semispinal plane (ISP) block can anesthetize the dorsal rami of the cervical spinal nerves from C4 to T4. The GON, TON, and the dorsal rami of the inferior level cannot be blocked with a single injection. To elucidate this phenomenon from an anatomical standpoint, we performed an ISP block either alone or with a GTO block using water-based acrylic dye in three thiel-embalmed cadavers. Both dyes were clearly separated by the tendinous septum running obliquely inside the semispinalis capitis muscle (SCA). The tendinous septum of the SCA may have a relatively strong connection with the dorsal edge of the semispinalis cervicis muscle, and this structure may stem the injectate spread. Therefore, the GON and TON, running through the medial head of the SCA, and the dorsal rami of the inferior level are spatially separated by the tendinous septum, and cannot be blocked with a single injection.

Introduction Intercostal nerve block and neurolysis are widely used procedures, but their injectate spread has not been well understood. Previous studies have reported unexpected outcomes (paravertebral or epidural anesthesia) and spinal cord injury after intercostal nerve block and neurolysis. To investigate a possible mechanism for these complications, we aimed to visualize the flow of liquid injected near the intercostal nerve, using cadavers. Methods We performed a simulated intercostal nerve block study using two Thiel-embalmed cadavers. Dye was injected into the interfascial plane between the internal and innermost intercostal muscles under ultrasound guidance (blue, 10 ml) or under direct vision (green, 5 ml). Results Dye leakage began with injection of only 0.5–2 ml and occurred between the innermost intercostal muscle fibers. The dye injected around the intercostal nerve penetrated into the extrapleural space and reached the paravertebral space. Conclusions Injectate placed around the intercostal nerve easily penetrate the extrapleural space and reach the paravertebral space. Intercostal nerve block or neurolysis has a risk of impairing at least the sympathetic chain and conceivably affecting the central nervous system.

PurposeIn some headache disorders, for which the greater occipital nerve block is partly effective, the third occipital nerve is also suggested to be involved. We aimed to establish a simple technique for simultaneously blocking the greater and third occipital nerves.MethodsWe performed a detailed examination of dorsal neck anatomy in 33 formalin-fixed cadavers, and deduced two candidate target points for blocking both the greater and third occipital nerves. These target points were tested on three Thiel-fixed cadavers. We performed ultrasound-guided dye injections into these points, examined the results by dissection, and selected the most suitable injection point. Finally, this target point was tested in three healthy volunteers. We injected 4 ml of local anesthetic and 1 ml of radiopaque material at the selected point, guided with a standard ultrasound system. Then, the pattern of local anesthetic distribution was imaged with computed tomography.ResultsWe deduced that the most suitable injection point was the medial head of the semispinalis capitis muscle at the C1 level of the cervical vertebra. Both nerves entered this muscle, in close proximity, with little individual variation. In healthy volunteers, an anesthetic injected was confined to the muscle and induced anesthesia in the skin areas innervated by both nerves.ConclusionsThe medial head of the semispinalis capitis muscle is a suitable landmark for blocking the greater and third occipital nerves simultaneously, by which occipital nerve involvement in various headache disorders may be rapidly examined and treated.

Aim The present study aimed to examine whether heart rate variability (HRV) indices in depressed patients measured at return to work after sick leave are related to the outcome of reinstatement. Methods This study included 30 workers who took a leave of absence due to major depressive disorder. HRV was measured twice, once when participants left work and another when they returned to work. One month after returning to work, 19 participants continued their original work (successful return group), while 11 failed to perform their original work (unsuccessful return group). HRV indices including high‐ and low‐frequency components (HF and LF) were calculated in three conditions within a session lasting for about 5 minutes, initial rest (Rest), mental task (Task), and rest after task (After), and were compared between the two participant groups. Psychological states were evaluated using Self‐rating Depression Scale and State‐Trait Anxiety Inventory. Results No significant differences were observed in the HRV indices on leaving work between groups. On returning to work, the “unsuccessful return group” exhibited lower HF Rest score, higher HF Task/Rest ratio, and higher LF/HF Rest score than the “successful return group.” Psychological scores improved in both groups. Conclusion These results indicate that autonomic dysregulations revealed by HRV measurement at return to work after a leave of absence in MDD patients were related to the outcome of reinstatement and can serve as useful information for the assessment of the risk of unsuccessful return. Autonomic dysregulations revealed by heart rate variability measurement at return to work after sick leave in depressed patients were related to the outcome of reinstatement and can serve as useful information for the assessment of the risk of unsuccessful return.

Background and AimsStellate ganglion block (SGB) is conventionally performed at the C6 vertebral level; however, this method poses the risk of accidental nerve blockade and vascular injury. We propose a novel approach, first-rib neck SGB (1RN-SGB), that effectively minimises these risks (figure 1).Methods[Case series] Ten patients underwent 1RN-SGB with 3–5 mL of 1% lidocaine after confirmation of contrast imaging using 3–4 mL of iohexol. Clinical outcomes, adverse effects, and extent of contrast spread were recorded. [Cadaveric study] 1RN-SGB was performed on four Thiel-embalmed cadavers (six sides) with 3 or 6 mL of 0.4% indigo carmine injected. Dye spread and nerve involvement were assessed by dissection.Results[Case series] 1RN-SGB successfully achieved pain relief in all patients with Horner’s sign. Two patients reported paralysis of the ulnar side of the hand and forearm. No additional adverse events were reported. Contrast spread reached adjacent to the T1 vertebra (figure 2). [Cadaveric study] The stellate ganglion was completely stained with 6 mL of dye but only on the lateral surface by 3 mL (figure 3). The sympathetic trunk was consistently stained at C7-T2. Recurrent laryngeal, vagus, and phrenic nerves were not stained. C8 and T1 nerves were stained in all cadavers.Abstract EP158 Figure 1The ultrasound image and the procedure of 1RN-SGB[Image Omitted. See PDF.]Abstract EP158 Figure 2The contrast spread after injection of 4 mL of iohexol[Image Omitted. See PDF.]Abstract EP158 Figure 3The dye spread after injection of 3 mL of 0.4% indigo carmine[Image Omitted. See PDF.]ConclusionsAlthough 1RN-SGB demonstrates consistent effects, its pathway may differ from that of conventional SGB. 1RN-SGB effectively reduces severe complications; however, it is crucial to note the unintentional blockade of C8 and T1 nerves.

To assess the effects of age on recovery of psychomotor function for propofol sedation during spinal anesthesia. Propofol was continuously infused during surgery and spinal anesthesia in 15 elderly patients (65-85 yr-old) and 15 younger patients (20-50 yr-old). Infusion rates were adjusted to maintain an appropriate level of sedation using the bispectral index (range 60-70). The sedative infusion was discontinued at the end of surgery. The early recovery times from the end of propofol infusion to opening of eyes on command, sustaining a hand grip, and recall of name were noted. Psychomotor function, as measured by the Trieger's dot test, was evaluated before anesthesia and 30, 60, 90, 120 min after the end of propofol infusion. The duration of anesthesia was 142 +/- 55 min and 134 +/- 61 min in the elderly and younger patients, respectively. No differences were observed in early recovery times between elderly and younger patients (opened their eyes on command, 6.3 +/- 4.0 min and 5.2 +/- 2.6 min; sustained a hand grip, 7.2 +/- 3.9 min and 6.1 +/- 3.5 min and recalled their name, 8.0 +/- 4.5 min and 6.5 +/- 3.8 min, P > 0.05 ). The recovery of psychomotor function in the elderly took longer compared with the younger patients, and psychomotor function in the elderly recovered at 120 min after the end of propofol infusion. Early recovery times following propofol sedation is similar between elderly and younger patients, but recovery of psychomotor function in the elderly is delayed compared with younger patients.

Investigation of isotope effects on superconducting transition temperature ( T c ) is one of the useful methods to examine whether electron–phonon interaction is essential for pairing mechanisms. The layered BiCh 2 -based (Ch: S, Se) superconductor family is a candidate for unconventional superconductors, because unconventional isotope effects have previously been observed in La(O,F)BiSSe and Bi 4 O 4 S 3 . In this study, we investigated the isotope effects of 32 S and 34 S in the high-pressure phase of (Sr,La)FBiS 2 , which has a monoclinic crystal structure and a higher T c of ~ 10 K under high pressures, and observed conventional-type isotope shifts in T c . The conventional-type isotope effects in the monoclinic phase of (Sr,La)FBiS 2 are different from the unconventional isotope effects observed in La(O,F)BiSSe and Bi 4 O 4 S 3 , which have a tetragonal structure. The obtained results suggest that the pairing mechanisms of BiCh 2 -based superconductors could be switched by a structural-symmetry change in the superconducting layers induced by pressure effects.