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Regional Anesthesia & Pain Medicine

RAPM is your authoritative medical source for regional anesthesia and pain knowledge – from pediatric

05/01/2026

📊 Can an axillary approach improve axillary nerve blocks?

In this cadaveric study, investigators evaluated an ultrasound-guided axillary approach to axillary nerve block and assessed injectate location and spread.

Key findings:
✅ Axillary nerve identified in all specimens
✅ Blue latex consistently targeted the bifurcation of axillary nerve branches
✅ Methylene blue spread covered all major motor branches in all specimens
✅ Mean injection location was 0.96 cm from the branch bifurcation
✅ The approach avoided reliance on identifying the posterior circumflex humeral artery, a common limitation of posterior approaches

💡 Why this matters:
This technique may provide a simpler alternative to conventional posterior ANB, particularly when used alongside suprascapular nerve block as a phrenic-sparing alternative to interscalene block.

✨ The takeaway:
The axillary approach may offer reliable branch coverage with favorable sonographic accessibility, supporting future clinical evaluation.

🔗 Read the full study:
https://doi.org/10.1136/rapm-2025-107503

04/30/2026

📊 Can a trans-quadrangular space approach improve axillary nerve blockade?
This cadaveric simulation study evaluated a novel ultrasound-guided TQS approach to selective axillary nerve blockade.

⚠️ Key findings:
✅ Main axillary nerve trunk stained in 100% of injections
✅ Anterior division stained in 83%
✅ Posterior division stained in 90%
✅ Minimal unintended spread
• Radial nerve lightly stained in 25%
• No musculocutaneous or posterior cord staining

💡 Why this matters:
This posterior technique targets the nerve within the quadrangular space rather than after exit from it, potentially improving articular branch coverage while supporting phrenic-sparing shoulder analgesia.

- Additional practical advantage:
✔ Performed in lateral position without shoulder abduction, potentially useful in painful or mobility-limited patients.

✨ The takeaway:
The TQS approach demonstrated anatomical feasibility, selective spread, and may warrant clinical evaluation as a novel axillary nerve block technique.

🔗 Read the full study:
https://doi.org/10.1136/rapm-2026-107774

04/23/2026

🔍 Debunking myths in facial pain diagnosis

Facial pain—especially trigeminal neuralgia—remains frequently misdiagnosed, leading to ineffective treatments and prolonged suffering.

A recent ASRA multidisciplinary paper in RAPM highlights common misconceptions that can misguide diagnosis and management.

Key points:
⚠️ Facial pain diagnosis is often clouded by training myths
🧠 MRI is not routine—reserved for suspected trigeminal neuralgia
📌 Neurovascular compression ≠ diagnosis (only helps guide MVD planning)
🎯 Diagnosis is clinical first—not imaging-driven

Bottom line:
Getting the diagnosis right is the most important step in avoiding unnecessary procedures and improving outcomes.

👉 A strong reminder: treat the patient, not the scan

🔗 https://doi.org/10.1136/rapm-2025-107382

04/21/2026

🔍 Plain vs hyperbaric bupivacaine—does baricity impact spinal anesthesia in TKA?

A recent randomized, double-blinded trial compared plain vs hyperbaric 0.5% bupivacaine for spinal anesthesia in total knee arthroplasty.

Key Findings:
📉 Similar maximal MAP drop (~33% in both groups)
📊 No difference in nadir BP or hemodynamic trends
🤢 Comparable nausea/vomiting and vasopressor use
⏱️ No group effect over the first hour post-spinal

Takeaway:
At 10 mg intrathecal dose, plain and hyperbaric bupivacaine performed similarly for early hemodynamic stability.

👉 Baricity alone may not meaningfully influence hypotension risk in this setting.

🔗 https://doi.org/10.1136/rapm-2025-107546

04/20/2026

🫀 Regional anesthesia in pediatric cardiac surgery—does it help?

A RAPM meta-analysis (31 RCTs, n=2245) found 👇

⬇️ Opioid use (intraop + 24h)
⏱️ Faster extubation + ↓ ICU stay
⏳ Longer time to first analgesia

But…
⚠️ Evidence = low quality
⚠️ High variability between studies

Bottom line:
👉 Promising, but far from definitive

🔗 https://doi.org/10.1136/rapm-2025-107470

04/17/2026

🔍 PENG block for hip arthroscopy—worth it?

A recent RCT in RAPM looked at preop PENG block for ambulatory hip arthroscopy 👇

What they found:
❌ No improvement in 24h opioids or QoR
⏱️ ↓ PACU opioids + shorter PACU stay
⚖️ No difference in pain, 48h opioids, or side effects

Bottom line:
👉 Limited early benefit, no impact on overall recovery
👉 Not ready for routine use—but may help select patients in PACU

📌 Postop (rescue) PENG block = area to watch

🔗 https://doi.org/10.1136/rapm-2026-107706

04/16/2026

🎙️ Episode 50: Pro–con debate on perioperative gabapentinoids: a nuanced approach is the best one

💡 What is the role of perioperative gabapentinoids in today’s practice?

In this episode, Brian Sites, MD, joins Eric Schwenk, MD, and Kishor Gandhi, MD, for a thoughtful discussion on the benefits, risks, and why a nuanced, patient-specific approach matters.

🎧 Listen now and stay up to date on the latest conversation in regional anesthesia and pain medicine.

🔗 https://rapmfocusbmj.podbean.com/e/episode-50-pro%e2%80%93con-debate-on-perioperative-gabapentinoids-a-nuanced-approach-is-the-best-one/

04/03/2026

🚨 Suprascapular Nerve Blocks: Anatomy Matters—Down to the Fascicles

🧠 It is often believed that the target for a suprascapular nerve block in terms of landmarks and needle position—but a new article in RAPM highlights that the nerve’s microanatomy changes along its course, which may have real implications for technique selection and safety.

📊 Findings: The suprascapular nerve shifts from mostly monofascicular proximally (cervical segment) to increasingly multifascicular distally (supraspinous/infraspinous fossae), with important branching and tissue relationships.

💡 Takeaway: Where one targets the nerve may influence block performance and risk.

🔗 https://doi.org/10.1136/rapm-2026-107686

04/02/2026

🚨 Clear Solutions? Crystallization in Local Anesthetic Cocktails

🧪 New study in RAPM: common local anesthetic + adjuvant mixtures used in regional anesthesia can crystallize, raising safety concerns.

🔑 Key takeaways:
• Lidocaine mixtures: no crystals detected
• Mepivacaine/ropivacaine mixtures: crystals seen in most combos
• Worst combo: ropivacaine + bicarbonate
• Micropore filters (5 µm or 0.2 µm): reduced crystals, but often did not eliminate them, especially over time or with larger volumes

🔗 https://doi.org/10.1136/rapm-2026-107700

03/31/2026

🚨 Can Liposomal Bupivacaine Upgrade VATS Recovery?

🫁 In RAPM, a new RCT studying video-assisted thoracoscopic surgery (VATS) patients: liposomal bupivacaine vs bupivacaine + dexamethasone for thoracic paravertebral block (TPVB).

📊 Results: Liposomal bupivacaine extended analgesia ~56% (1160 vs 743 min) and improved early pain scores. Exploratory findings suggested less POD1 oxycodone, earlier ambulation/flatus, and higher satisfaction, with no difference in adverse events or length of stay.

💬 Would you use LB for longer-lasting TPVB in your VATS pathway?

🔗 https://doi.org/10.1136/rapm-2025-107478

03/30/2026

🚨 Does Anesthesia Shape Recurrence?

📚 This RAPM article highlights how anesthesia choice may influence cancer outcomes after resection for non-muscle invasive bladder cancer (NMIBC).

💉 In a randomized trial (Seoul National University Hospital, 2018–2020), patients who received spinal anesthesia had lower 2-year recurrence than those who received general anesthesia (~27% vs ~40%). Disease progression was also higher with general anesthesia (15.2% vs 7.8%), though not statistically significant.

💡 This article helps reshape perioperative decision-making — moving anesthesia planning from “how we get through the case” to “how we optimize long-term outcomes.”

🔗 https://doi.org/10.1136/rapm-2024-105949

03/29/2026

🎧 New RAPM Focus podcast: Rethinking pain after C-section

💡 Instead of focusing only on pain scores, the SPACE-Postpartum model looks at a cluster of symptoms that shape recovery: Sleep, Pain, Affect, Cognition, Energy. Early patterns may help identify who’s at risk for chronic pain or impaired recovery—and guide earlier support.

Should postpartum recovery be measured beyond pain scores?

🔗 https://rapmfocusbmj.podbean.com/e/episode-49space-postpartuma-multidomain-biopsychosocialframeworkfor-predictingchronic-pain-and-impairedrecoveryaftercesareandelivery-%e2%80%93proof-of/

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