OKOJ, Volume 8, No. 2

Continuous interscalene blocks involve the insertion of a perineural catheter along the brachial plexus to provide a continuous local anesthetic infusion with or without patient-controlled bolus dosing. Most commonly used to produce surgery-specific analgesia for major shoulder surgery, continuous interscalene blocks may also play a role in improving surgical outcomes by facilitating early physical therapy as a result of superior pain control. This article reviews the current evidence supporting the benefits of continuous interscalene blocks in improving the quality and duration of postsurgical recovery, as well as indications, contraindications, potential complications, and adverse effects. Although a limited number of studies on continuous interscalene blocks have been published, findings suggest improvements in the time to achieve set discharge criteria, pain control, and mobility that meet or exceed surgeon-defined physical therapy goals and patient satisfaction. While the benefits in terms of rehabilitation appear to be limited to the immediate postoperative period at present, the authors recommend the use of continuous interscalene blocks for postoperative pain control following major shoulder surgery.

Fractures and dislocations of the subaxial cervical spine and cervicothoracicjunction are common and potentially devastating injuries. Depending on the severity of injury, outcomes range from full recovery to varying degrees of temporary or permanent incomplete or complete neurologic compromise to death. The most common surgical techniques employed in treating these injuries are anterior cervical diskectomy and instrumented fusion, anterior cervical corpectomy with interbody strut graft placement and instrumented fusion, posterior spinal fusion with or without instrumentation, and anterior or posterior iliac crest bone grafting. Treatment decisions are typically based on an understanding of the injury mechanism, degree of biomechanical instability, neurologic status of the patient, and individual patient factors. A better understanding of the epidemiology, diagnosis, classification, treatment options, and complications of these life-threatening injuries will allow the practicing clinician to maintain a high index of suspicion and appropriately manage patients.

Incidental dural tears are among the most common complications of spinal surgery, with an incidence of approximately 2% to 3% in primary cases. To a large extent, incidental durotomy may be reduced with careful surgical technique, with appropriate magnification and adequate visualization of the surgical field and epidural space. When a dural tear does occur, it should be suture-repaired, if possible. Watertight closure to prevent leakage is crucial for a positive outcome. If the tear is not amenable to watertight repair, it may be augmented with collagen patching, fibrin glue sealant, and drainage if necessary. Successful repair of a dural tear typically leads to an uneventful recovery; however, left untreated (or with failure of treatment), dural tears can lead to persistent CSF leakage,durocutaneous fistula formation, pseudomeningocele, or, more rarely, meningitis.