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Here we have a case of mandibular osteosarcoma resection. We opted to perform postoperatively a mandibular nerve block using the extraoral landmark technique. The LA we used : Levobupivacaine 0.5% 5 ml and Lidocaine 2 % 5 ml. Postoperative analgesia was perfectly satisfactory.

Considering the details provided in the case, how would you proceed with managing this patient’s condition? Could you detail the potential treatment strategies you would explore and justify your choices?

Challenges in Regional Anesthesia Adoption:
I recently came across a publication in Cureus that highlights the challenges in the wider adoption of regional anesthesia: extensive experimentation. With the increasing use of ultrasound, the regional anesthesia community has seen a surge in new techniques and approaches. This proliferation has led to complexities that even classical anatomy struggles to explain.
Rather than standardizing the indications, pharmacology, and techniques of highly reproducible methods, the regional anesthesia community has introduced additional anatomical classifications to help make sense of numerous hypothetical techniques developed through cadaveric dissections that could be more suited for cadavers than for actual patients. Attempting to reproduce the multitude of new injection techniques and their endless variations methodology and pharmacology in clinical settings could even raise ethical concerns about promoting unvalidated methods.
Journals, competing for readership, often prioritize new and experimental approaches, complicating the practice of regional anesthesia and making it harder to standardize and implement effectively. Consequently, regional anesthesia meetings are filled with discussions on new techniques, while existing, wellestablished ones remain unstandardized.
Take, for example, this table from the publication. In patient #1, the authors reported a combination of PENG and sacral level ESP blocks. For this, they used a whopping 55 ml of 0.2% ropivacaine, amounting to a dose of over 2 mg/kg in a patient with a BMI of 18, barely 50 kg, and 85 years of age—posing a high risk of LAST. I would advise against using such a large volume/dose for fascial, fast absorption infiltration over a large surface. Additionally, steroids and dexmedetomidine should not be used in fascial plane blocks, if at all, as this is mere parenteral administration. Lastly, what is the value of additives compared to replacing ropivacaine with bupivacaine as a longer-lasting local anesthetic?
Thoughts? Would you recommend the technique from this publication?