From pain to precision: A journey of Regional Anaesthesia

Dr. Soma C Cham

Associate Professor, Dept. of Anaesthesiology
TCC, GMC, Nagpur

The evolution of regional anaesthesia is the resultant of innovative minds both trying to bring in change with invention of new techniques and drugs for betterment and advancement in civilisation, with alleviating pain perhaps being the crux of existence. This can be very arbitrarily divided into three ages, the early era, the dark era and the modern era with indistinct phases of separation. The early era in the evolution of regional anaesthesia could be described as excerpts from world history.

Ancient Egyptians used a variety of analgesics like hyoscyamine, scopolamine, opium poppy, beer, juniper, and yeast for treating ‘pain within the body’. Ancient Indian culture used herbal medicine and yoga to overcome pain and create internal balance Ancient Chinese used acupuncture to properly channel negative energies and treat pain. Ancient Greeks gave the world Hippocrates (460–370 BCE) who believed in the healing power of nature and focused on a rational approach to diagnosis and treatment rather than one based on superstition.

1. Aristotle described pain as an emotion that was situated in the heart (384–322 BCE)  Galen of Pergamon described that people recognized that the brain was the organ responsible for pain sensation (130–201 ADE).  Avicenna described how pain sensation could be altered in various disease states (980–1037 ADE) The dark era encompasses over a lull 1½ millennium years and remains as an unpleasant time period.
2. Scattered information reveal the use of regional anaesthesia, first reported by Paré (France) in 1564. He obtained local anaesthesia by nerve compression but enormous advancement in regional anaesthesia started thereon from 1900s.

• Early 1800s – Newton and Hartley described the potential role of nerves in transmitting noxious stimuli from the periphery to the brain
• 1840s – Importation of coca leaves from Peru, known for both its analgesic and hallucinatory properties
• 1855 – Isolation of active alkaloid of cocaine, “erythrolyxin” by German chemist Fredrick Gaedcke
• 1860 – Purification and naming of cocaine by Albert Nieman
• 1880 – Basil von Anrep studied pharmacology of cocaine & reported injecting cocaine into his arm produced numbing of his skin
• 1884 – Koller describes the surgical use of topical cocaine, cocainization of the eye for production of local anesthesia
• 1884 – Halsted & Hall, infiltrated cocaine to numb surgical fields. Also first to describe the use of cocaine to block nerves (1st nerve to be blocked – mandibular nerve), including a report of brachial plexus anesthesia by injection under direct vision
• 1885 – Corning produced the first accidental epidural anesthetic with cocaine
• 1887 – Corning is also credited with the first regional anesthetic peripheral nerve block after injecting a solution of cocaine around the median cutaneous antibrachii nerve
• 1887 – Braun demonstrated toxicity of cocaine in proportion to its rate of absorption, and recommended the addition of epinephrine to decrease its rate of absorption and increase the duration of anesthesia
• 1889 – August Bier & assistant August Hildebrandt produces the first subarachnoid block, using 5 mg cocaine (Fortunately, this occurred in the aseptic era did not mar the history of neuraxial block)
• 1889 – Fredrick Tate and Guido Caglieri in San Francisco, performed surgical procedures under spinal anesthesia and popularized it because of its simplicity and low toxicity 3
• 1901 – Sicard treated sciatica with sacral, caudal peridural injections of local anesthetic
• 1901 – George Crile, founder of the Cleveland Clinic & the American College of Surgeons, explored effects of anesthesia on the phenomenon of “surgical shock”
• 1903 – Amylocaine (stovaine) synthesized by Niemann – to overcome cocaine drawbacks of short duration and addiction, but nerve irritant
• 1904 – Procaine synthesized by Alfred Einhorn in Germany but short duration with new problem of allergic reaction
• 1905 – Braun in Germany published the first textbook describing regional anaesthesia techniques fathered by surgeons.4
• 1908 – August Bier described the first “intravenous regional anesthesia”
• 1909 – William Babock advocated the use of hypobaric spinal anesthesia, amylocaine (stovaine) mixed with alcohol, strychnine, distilled water and lactic acid
• 1911 – Georg Hirschel described the axillary brachial plexus block and D Kulenkampff described the supraclavicular brachial plexus block
• 1912 – Georg Perthes (Germany) first reported the clinical use of electrical nerve stimulation for nerve blocks
• 1921 – Fidel Pagés-Miravé uses epidural injection
• 1922 – Gaston Labat’s text was the first comprehensive practical manual of regional techniques in English ‘Regional Anesthesia: Its Technic and Clinical Application’ which resembled those in Pauchet’s French text (sold 7000 copies)
• 1923 – Organization of first American Society of Regional Anesthesia (ASRA) by Gaston Labat and his enthusiastic followers
• 1923 – Lincoln Sise pioneered the use of hyperbaric solutions, administered to patients positioned laterally and in a slight Trendelenburg’s position, with the head and shoulders elevated. He tilted the table to adjust the block height to an optimum level.
• 1923 – Green’s rounded bevel needle was introduced, subsequently shown to reduce the incidence of headaches.
• 1925 – Dibucaine synthesized but narrow therapeutic range
• 1927 – George Pitkin invented and popularized hypobaric solution, he named “Spinocain”, a mixture of procaine (0.195 gm), strychnine (0.0022 gm, nominally to act as a vasoconstrictor), and alcohol (0.324 gm) in 2.2 ml 5,6
• Pitkin also described effect of position and gravity on the spread of spinal anesthesia, and developed a tilt indicator & hyperbaric solution for obstetrical anesthesia
• 1931 – Dogliotti publishes and popularises epidural technique
• 1932 – Tetracaine used clinically but limited to spinal anaesthesia
• Rovenstine, a founder of the ASA, largely abandoned the operating room, to apply regional techniques to patients having problems with pain, presaging a movement that gained momentum in the second half of the century.
• 1939 – Dominated by surgeons ASRA dissolved with advancement in GA
• 1940 – Lemmon introduces the continuous (malleable) spinal needle, intermittent injections presaged the development of “continuous” spinal anesthesia
• 1942 – Robert Hingson and Waldo Edwards described continuous caudal anesthesia for lower extremity surgery and later extended to labor and delivery, along with Gertie Marx & John Bonica7
• 1943 – Lofgren and Lundvquist synthesized lidocaine and sold the patent to the Astra Pharmaceutical Company in Sweden.
• 1944 – Touhy provides continuous spinal anesthesia through a small gauge urinary catheter.8
• 1947 – Curbelo describes continuous epidural anesthesia
• 1947 – Gordh describes the clinical use of lidocaine
• 1948 – Daniel Moore established a Department of Anesthesia at the Clinic and obtained approval for a residency program in 1948.
• 1949 – Manuel Curbelo of Cuba used the Tuohy needle to introduce a ureteral catheter into the epidural space enabling the first continuous epidural anesthetic.9
• 1951 – John Lundy developed concept of “balanced anesthesia” wherein a hypnotic agent produced anesthesia, neuromuscular blocking drugs facilitated relaxation, and a regional technique provided postoperative pain relief.
• 1952 – Daniel Moore published his textbook on regional anesthesia, a richly illustrated practical guide.10
• Benjamin Covino, oversaw research on the new long-acting amino-amide local anesthetics as Medical director of Astra Pharmaceutical Products, published 150 papers and five textbooks on regional anesthesia topics,
• spearheaded the “third phase” of the development of regional anesthesia, the “Scientific Era”.11
• 1952 – 2-chloroprocaine used clinically
• 1954 – The middle of the 20th century marked a nadir of regional techniques, partly due to improved drugs and techniques for general anesthesia & permanent paralysis caused by spinal anesthesia, badly publicized disaster.12
• 1957 – Mepivacaine used clinically
• 1960 – Prilocaine used clinically
• 1963 – CM Holmes described IVRA through the percutaneous approach, using the “new” lidocaine, that became an accepted technique.
• 1962 – Greenblatt and Denson reported their use of a portable nerve stimulator for nerve localization
• 1963 – Bupivacaine used clinically
• 1966 – Battery powered portable nerve stimulators first appeared in clinical practice
• 1969 – Gerard Ostheimer led one of the first studies of the efficacy of epidural blood patches.
• 1972 – Chapman uses a nerve stimulator to guide local anesthetic injection
• 1972 – Etidocaine used clinically
• 1975 – Alon P Winnie with P Prithvi Raj, and co-opted L Donald Bridenbaugh, Harold Carron and Jordan Katz,13 to join together as “founding fathers”, resurrecting the original ASRA Organization of second American Society of Regional Anesthesia.
• Bonica became Director of the second ASRA, founding member of the International Society of Pain, published the first major American textbooks on Regional anesthesia especially in obstetrics and management of patients with chronic pain. he fostered a multidisciplinary pain clinic and formalized the role of the anesthesiologist for the management of complex pain syndromes, including the use of diagnostic and neurolytic nerve blocks.
• Alon P Winnie, pioneer of regional techniques, simplified single-injection techniques for brachial plexus14 and lumbar plexus anesthesia,
• 1976 – First Scientific meeting and first journal of society – Regional Anesthesia
• 1976 – Yaksh and Rady describe the use of spinal opioids for analgesia
• 1977 – Selander provides continuous axillary nerve blockade
• 1978 – La Grange and colleagues first used a Doppler ultrasound to guide a supraclavicular brachial plexus block
• 1979 – Cousins et al popularize epidural analgesia
• 1979 – Bupivicaine cardiotoxicity discovered after unintentional intravascular injection
• 1979 – Donald (Bruce) Scott, Britisher, noted for his research on the management of hypotension in the supine parturient, was the founding president of the European Society of Regional Anesthesia (ESRA).
• 1970-1980s – Egor Lanz, Germany, worked on epidural morphine analgesia, and scientific documentation of the distribution of anesthesia with the various approaches to brachial plexus blockade.
• Albert van Steenberge promoted techniques such as low-dose epidural analgesia for obstetrics, and the combined spinal-epidural technique
• The technology of needle and catheter design improved. New fine-gauge needles with rounded bevels produced a lower incidence of post-dural puncture headache, reviving this regional technique.
• Development of smaller gauge Tuohy-type needles demanded a parallel development of smaller epidural catheters were flexible yet rigid.
• Adopted for obstetrical anesthesia, catheters became mainstay for postoperative analgesia both for continuous peridural blockade
• 1980s – Opioids placed in the spinal and epidural space were shown to provide segmental analgesia without anesthesia or systemic opioid effects
• 1980 – 2-chloroprocaine neurotoxicity described following unintended subarachnoid injection of a large dose of preservative-containing drug
• 1981 – Philip Bromage in his textbook described the anatomy and physiology of epidural blockade (including epidural opioid analgesia).15
• 1984 – Specially designed needles became available for electrostimulation of nerves with electrically insulated shafts but naked metal tips
• 1985 – European Society of Regional Anesthesia founded
• 1989 – Asian-Oceanic Society of Regional Anesthesia emerged
• 1990s – Continuous blockade of peripheral nerves, catheters were used. Small catheters led to development of portable mechanical and electrical pumps to deliver local anesthetic solutions for 2–3 days.
• 1990s – Anesthesiologists at the University of Vienna began to explore the use of US to guide peripheral nerve blocks
• 1993 – The Latin American Society of Regional Anesthesiology was founded
• 1994 – Kapral introduces ultrasound detection and block of peripheral nerves 16,17, sonoanatomy of the brachial plexus is described
• 1994 – The New York School of Regional Anesthesia website appears (NYSORA.com) established by Admir Hadzic, with expanding Internet Technology
• 1997 – Ropivacaine used clinically
• 1998 – Weinberg describes lipid rescue for local anesthetic cardiotoxicity
• 1980s – 1990s – Peripheral nerve stimulators now aided nerve localization. The development of insulated needles, which concentrated the electrical current at the tip of the needle, further improved efficacy of nerve localization.

2000 onwards…

• The advent of portable usg machines and use in operating theaters allowed for regional blocks to be administered under direct vision.
• In the ensuing years, ultrasound technology advanced in parallel with the understanding of its use and the development of block techniques which suited the use of ultrasound.
• The emergence of newer regional anesthesia techniques, called truncal blocks, allowed for the injection of local anesthesia into a muscle plane, rather than identifying a specific nerve.
  In the sojourn from pain to precision in regional anaesthesia, we now tread forward with the use of AI to improve the accuracy and safety of ultrasound-guided regional anesthesia.

Reference:

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