Training in regional anesthesia is one of the strengths of our residency program. A small group of dedicated faculty concentrate their clinical time instructing residents in the principles and practice of regional anesthesia. The Department of Orthopedic Surgery at Columbia University Medical Center is consistently ranked one of the best in the country, and surgery involving the extremities, including all types of open fracture repair, corrective procedures of the hands and feet, and joint arthroscopy are performed daily, most of them under regional anesthesia. Our Shoulder Service is very active, with more than 95% of the shoulder operations performed under an interscalene brachial plexus block.

Major physiologic alterations brought about by general anesthesia can be avoided by the use of regional anesthetic techniques, and perioperative risk can be favorably influenced. Many of our blocks are performed with long acting agents that provide not only intraoperative anesthesia, but postoperative analgesia as well. The placement of perineural catheters (upper and lower extremity) and the use of continuous regional analgesia techniques are utilized to provide postoperative analgesia for an extended period of time. The combination of an excellent caseload, a dedicated anesthesia faculty, and a high level of patient and surgeon satisfaction with regional anesthesia, make this a wealthy and rewarding clinical experience and is consistently one of the clinical rotations requested by our residents.

The first rotation in regional anesthesia takes place in the CA-1 year. During this month, the resident performs primarily peripheral nerve blocks, including interscalene, supraclavicular, infraclavicular, axillary, femoral compartment, sciatic, popliteal and ankle blocks, for routine orthopedic procedures on the extremities. Residents will gain experience performing these blocks predominantly under ultrasound guidance with the occasional use of a peripheral nerve stimulator. Epidural, spinal and combined spinal-epidural techniques are also taught. Management of moderate to deep sedation as an adjunct to regional anesthesia is developed during this month. The pharmacology and clinical use of local anesthetic agents as well as the anatomy and clinical application of peripheral and neuraxial blocks are major topics of study during the rotation.

In the second year, the resident is expected to decide independently which blocks will be appropriate for the planned procedure and which agents to use, and to defend their choice with the attending anesthesiologist. They are expected to identify landmarks for performance of regional techniques with minimal assistance, and initiate blocks for postoperative pain management. In addition to reviewing previously covered topics, new topics are introduced, including considerations for hip and knee replacement, thromboembolic prophylaxis, blood sparing techniques, orthopedic oncology as well as spinal trauma and surgery.

A CA-3 rotation is optional, but many seniors want additional experience with peripheral blocks. The CA-3 resident is expected to have mastered basic knowledge related to regional anesthesia, and should be able to perform regional techniques and manage patients during surgery with minimal assistance. The senior resident is introduced to controversial topics in regional anesthesia, exposed to relevant articles in the literature, and is encouraged to discuss pertinent issues with their attending in an "Oral Board" format. Brief clinical scenarios, such as, management of a quadriplegic patient for shoulder surgery, a patient with sudden dyspnea following placement of an interscalene block, or a patient with a history of 'collapse' after local anesthetic administration in the dentist's office, are presented by the attending, and the resident is expected to be able to assess the situation, answer questions, decide treatment options, and defend opinions.

The CA-3 resident will participate in the placement of peripheral nerve catheters for postoperative continuous regional analgesia. This is an exciting technique that is gaining in popularity, and is poised to become the preferred technique for managing postoperative pain following certain orthopedic and other surgical procedures.

In addition, the CA-3 resident will be available to assist with regional anesthesia techniques outside of the orthopedic surgery core. These techniques include paravertebral blocks for breast surgery, brachial plexus blocks for vascular procedures, and transversus abdominal plane (TAP) blocks following various abdominal procedures. In this way, the resident is exposed to the full spectrum of regional anesthesia techniques that are utilized for intraoperative anesthesia and postoperative analgesia.