I would like to thank Drs. Afsin and Ahmet Cargi Uysal for their comments on my article. It had been 3 months since I had begun my residency in the plastic surgery department of Northern General Hospital, in Sheffield, England, when I came across with the transthecal digital block for anesthesia of the fingers. Mr Sarhadi,1 an excellent surgeon and colleague, was working at our department at that time and he taught me the technique. I still remember him sitting in front of the department computer explaining to me how close he was to revealing the secret of anesthesia after the transthecal digital block through his cadaver studies. I became so enthusiastic about this technique that during the next 3 years that I worked in the department, I performed all my finger operations using this anesthetic technique.
However, my early experience with this technique was not without some problems. Not all of my blocks were successful and sometimes I needed to use an anesthetic dose higher than 2 ml. The most common mistake during that time was that I missed the intrathecal space and injected either too superficially or very deeply. A good tip that can help the surgeon to inject into the correct space is to ask the patient to flex the finger. If the needle moves in accordance with the finger movement, it is a good indication that you are in the right plane. It was also during those years that I began observing that some patients were complaining for pain during or after the anesthesia.
When I went back to Greece to continue my plastic surgery training, I decided to set up a study mainly to clarify the pain element of the transthecal block. Because of the learning curve of the technique, I performed all the blocks myself and they were 100 percent successful, but my initial observation regarding the pain was confirmed.
An alternative to the traditional transthecal block could be the modified transthecal digital block.2 Cummings et al.3 compared the modified transthecal digital block with the traditional digital block and found that with regard to pain perception, the two blocks were equal. However, they experienced some problems with the anesthesia distribution at the dorsal and radial proximal zones using the modified technique.
I agree with Dr. Uysal and Dr. Uysal that the transthecal block should be used for selective cases, but not because of the ineffectiveness of the technique but because of the pain that can be caused with its performance. Our goal is to achieve excellence in our patient care and, as much as possible, painless procedures. Consequently, I will continue to use the transthecal block, but in elective cases, such as in vascularly compromised digits, patients with needle phobia, and so on.
Evangelos G. Keramidas, M.D., E.B.O.P.R.A.S.
Flat 4, 33 Nottingham Place, London W1U 5LR, United Kingdom, [email protected]
1.Sarhadi, N. S., and Shaw-Dunn, J. Transthecal digital nerve block: An anatomic appraisal. J. Hand Surg. (Br.)
23: 490, 1998.
2.Whetzel, T. P., Mabourakh, S., and Barkhordar, R. Modified transthecal digital block. J. Hand Surg. (Am.)
. 22: 361, 1997.
3.Cummings, A. J., Tisol, W. B., and Meyer, L. E. Modified transthecal digital block versus traditional digital block for anesthesia of the finger. J. Hand Surg. (Am.)
. 29: 44, 2004.
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