ESRA Innsbruck Pain and Regional Anaesthesia cadaver

ESRA Pain and RA Cadaver Course Innsbruck 19-22 February 2020

Traditionally during the third week of February ESRA Cadaveric Pain and Regional Anaesthesia happened this year again in the beautiful city of Innsbruck, Austria. Both workshops have attracted 110 participants from 25 countries and offered state-of-the-art lectures, live scanning as well as cadaveric dissections and also offered needling the cadavers under real time ultrasound guidance.

Upon entering the magnificent old anatomy building in Innsbruck one can immediately appreciate the grandeur of this fantastic piece of art. All halls and theatres are filled with history and learning. It is impossible to not be impressed and everyone is anticipating this intense course with curiosity and expectance. (PIC)

The event was launched by Chronic Pain lectures and live model scanning on Wednesday afternoon. Dr Andrzej Krol from St George’s University of London, and Dr David Lorenzana from Balgrist University Hospital in Zurich, introduced the international Faculty: Dr Luis Valdez and Dr Gustavo Fabregat from Spain, Dr Severine Burke from Switzerland and overseas contingent from the UK and Northern Ireland: Dr Raja Reddy, Dr Anthony Allan, Dr Peter Merjavy.

After short introduction lecture by Dr Krol, about application of ultrasound in chronic pain interventions and recommended literature, a real Giant stepped in: Professor Bernhard Moriggl of Department of Anatomy, Histology and Embryology of Medical University of Innsbruck has been the pillar of research and practical applications of ultrasound in regional anaesthesia and pain medicine for more than three decades. Each of Professor Moriggl relevant sonoanatomy lecture was followed by a short talk from the faculty members about clinical applications, practical tips and a live model scanning with two screens projecting ultrasound images and probe position.

Following morning eight practical workshop stations were set up. There were four clinical targets commonly seek in clinical practice:

• Anterior neck: cervical roots (ventral rami of spinal nerves), “stellate ganglion” being middle cervical sympathetic ganglion and novel approach to suprascapular nerve under omohyoid muscle.
• Lateral and posterior neck: greater occipital nerve, cervical medial branches, posterior approach to suprascapular nerve and shoulder structures itself.
• Anterior abdominal wall: ilioinguinal, iliohypogastric nerves, both too common victims of herniorrhaphy, abdominal cutaneous nerves often overlooked cause of abdominal wall pain (ACNES), lateral cutaneous nerve of the thigh famous of causing meralgia paresthetica as well as periarticular injections to the hip and knee joint including its sensory branches ( PENG block and genicular nerves blocks)
• Lumbar spine and posterior pelvis shedding light on GPS (Gluteal Pain Syndrome), pudendal nerve and making caudal epidural and sacroiliac joint an easy target.

All four live model scanning stations were mirrored by the 4 cadaveric needling stations facilitating learning process. At each cadaveric station 10 min anatomical tutorial was provided on prosected specimen by a very knowledgeable and dedicated team of medical students carefully selected by Professor Moriggl and Dr Regina Irschick who were around to answer the most detailed anatomical questions. Anatomical knowledge refreshment was especially appreciated by delegates who visited anatomy lab for the first time since Medical School!

All rounded up in the evening at the Schindler Restaurant where the faculty, delegates and students entwined and were discussing and sharing their experience deep into the evening

If a reader of this newsletter already regrets missing the event, ESRA has introduced Cadaver Pain Workshops in a coordinated manner in the three different locations across Europe: Innsbruck, London, Madrid. Each course covers similar curriculum in a unique way related to the local specificity e.g cadaver embalming method, but always run by the top expert instructors approved by ESRA from all over the world. Mark your calendar for those events usually held in February, March and May each year respectively!

The following 2 days were entirely devoted to regional anaesthesia

Prof Paul Kessler (Frankfurt – Germany) introduced international faculty – Dr Steve Coppens (Leuven – Belgium), Prof Oya Yalcin Cok (Baskent – Turkey), Dr Dan Dirzu (Cluj Napoca – Romania), Dr Lukas Kirchmair (Schwaz – Austria), Dr Marcus Neumüller (Linz – Austria), Dr Slobodan Gligorijevic (Zurrich – Switzerland) and Dr Peter Merjavy (Craigavon – UK).

Lectures on the first day focused on upper and lower limb blocks, highlighting alternatives to classical interscalene block (superior trunk block) and various techniques for reducing hemidiaphragmatic paralysis for shoulder surgery. Costoclavicular block and its anatomical similarity with previously used nerve stimulation technique – vertical infraclavicular block were discussed at length. Axillary brachial plexus block is still considered a good alternative for novices in RA.

After a filled day of fantastic workshops, state of the art lectures and social mingling in the coffee breaks it was time to enjoy the dazzling Innsbruck bars and restaurants to top of the day with perfection.

The second day brought us more intriguing and more controversial topics, like a discussion on truncal blocks. The underlying message was that in appropriate hospital setting with high volume cases thoracic epidural analgesia and thoracic paravertebral block have still their place as the current evidence still supports their use.

Common issues of various fascial plane blocks are legion. Poorly defined point of injection. Vague criteria for successful, failed blocks and misuse of anatomical terminology (e.g. interfascial plane block is used for injection between fascia and bone …etc).

However truncal blocks have also revolutionized regional anaesthesia. Eventually the truncal thoracic and abdominal blocks created an interesting discussion about the anatomical base for various commonly used blocks, defining the fascia and interfascial plane, where all the delegates and faculty joined in.

Several techniques on how to prolong the duration of nerve blocks were also discussed including various additives, extended release preparations for local anaesthetics and NSAIDs as well as tips and trick for use of continuous catheter techniques with PCRA, intermittent boluses or continuous infusion of LA.

One of the highlights was the live scanning by Prof Moriggl. Being the knowledgeable anatomist that he is, he emphasized and stressed the importance of landmarks even in this age of ultrasound. With a simple explanation of the points of interest he demonstrated that he does not have to look for nerves, it’s simply there and immediately in view if you know your landmarks.

I think in the future we might even make some new workshops, where experts emphasize on anatomy and landmarks and can draw the complex anatomy on the body before they scan.

All Innsbruck workshops created very positive atmosphere for discussion and strengthened the position of cadaveric courses in current education in regional anaesthesia.

Thanks to Prof Bernhard Moriggl and his team from Anatomy Institute Innsbruck, Prof. Paul Kessler – Chair of ESRA workshops and Morgane Lanoy with Vivien Penning (ESRA & Kennes) everything was running very smoothly.

Those preparing for EDPM or EDRA will find the courses very valuable in refreshment in anatomy, sonoanatomy for regional anaesthesia and various chronic pain syndromes.