Acta Anaesthesiol Scand 2014; 58: 362–364 Printed in Singapore. All rights reserved
© 2013 The Acta Anaesthesiologica Scandinavica Foundation. Published by John Wiley & Sons Ltd ACTA ANAESTHESIOLOGICA SCANDINAVICA
doi: 10.1111/aas.12244
Case Report
Delayed quadriceps weakness after continuous adductor canal block for total knee arthroplasty: a case report Christopher Veal, David B. Auyong, Neil A. Hanson, Cindy J. Allen and Wyndam Strodtbeck Anesthesiology, Virginia Mason Medical Center, Seattle, WA, USA
Adductor canal catheters have been shown to improve analgesia while maintaining quadriceps strength after total knee arthroplasty. We describe a patient who underwent total knee arthroplasty that likely had delayed quadriceps weakness as a result of a standard continuous 0.2% ropivacaine infusion at 8 ml/h within the adductor canal. On the day of surgery, the patient was able to stand and ambulate with minimal assistance. On the first post-operative day after surgery, approximately 20 h after starting the ropivacaine infusion, profound weakness of the quadriceps was noted with no ability to stand. Contrast subsequently injected through the adductor canal catheter under
T
he adductor canal block provides analgesia for knee surgery while sparing quadriceps strength.1–3 Intermittent boluses and infusions of local anaesthetics at the adductor canal have been shown to improve post-surgical outcomes after total knee arthroplasty.4,5 It is hypothesised that the proximal spread of local anaesthetic may reach the efferent nerve to the vastus medialis, but usually does not spread to other motor fibres of the femoral nerve, which branch immediately distal to the inguinal ligament.6–9 Quadriceps weakness after total knee arthroplasty is a common phenomenon that can occur with and without the presence of a block.5 As of yet, there have been no formal evaluations of in vivo spread of injectate within the adductor canal. We present a case of delayed profound quadriceps weakness 20 h after continuous infusion of local anaesthetic at the adductor canal following total knee replacement.
Case description Consent: Written consent to publish this case report was obtained directly from the patient described below. A 58-year-old female presented for left total knee arthroplasty. Past medical history was significant for
362 bs_bs_banner
fluoroscopy revealed proximal spread approaching the common femoral nerve with as little as 2 ml of volume. This rare case of profound quadriceps weakness after a continuous adductor canal block reveals that local anaesthetic at the adductor canal can spread in a retrograde fashion towards the common femoral nerve, potentially resulting in quadriceps weakness. Accepted for publication 18 November 2013 © 2013 The Acta Anaesthesiologica Scandinavica Foundation. Published by John Wiley & Sons Ltd
obesity (height = 165 cm, weight = 113.6 kg, body mass index = 44 kg/m2) and obstructive sleep apnoea. A pre-operative adductor canal catheter was placed using in-plane ultrasound guidance at a point midway between the inguinal crease and the superior margin of the patella. The needle was advanced lateral to medial through the vastus medialis muscle and 15 ml 1.5% mepivacaine injected within the potential space to allow advancement of the catheter 1 cm past the tip of the needle.4,5 Surgical anaesthesia was provided by a spinal anaesthetic, and a tourniquet was placed near the site of catheter insertion during the operation. A standard continuous peri-neural infusion was initiated at the end of the procedure with ropivacaine 0.2% at 8 ml/h for post-operative analgesia.5,10 Following routine post-anaesthesia care, the patient was transferred to the hospital floor. Five hours after initiation of the continuous adductor canal infusion, she ambulated 7 m and performed a straight leg raise with excellent analgesia on the day of surgery. However, on post-operative day 1, after approximately 20 h of local anaesthetic infusion, she was unable to perform a straight leg raise or ambulate because of quadriceps weakness. Physical therapy confirmed knee buckling upon standing and inabil-
Quadriceps weakness adductor canal block
ity to ambulate. She continued to report excellent analgesia with a verbal numeric pain score of 0/10. Given the weakness, the peri-neural local anaesthetic infusion was stopped. Reassessment 6 h later revealed persistent quadriceps weakness with continued analgesia. Because of the persistent leg weakness, the patient was consented for a contrast study of the adductor canal catheter. Under fluoroscopy, the tip of the catheter was identified. One millilitre of Isovue M-300 contrast (Bipso GmbH, Singen, Germany) was then slowly injected via the catheter. Fluoroscopy demonstrated retrograde spread of the contrast proximally (Fig. 1). Four more sequential images were captured after additional 1 ml contrast boluses were injected to a total volume of 5 ml (Fig. 2). Fluoroscopic images clearly demonstrated preferential proximal spread towards the common femoral nerve, with minimal distal spread. Ten hours after discontinuation of the local anaesthetic
Fig. 1. Fluoroscopic image of the adductor canal catheter at midfemur. Dark contrast can be visualised preferentially spreading cephalad. Pre = image pre-contrast injection, 1 ml = image after 1 ml of contrast. White arrow = tip of the catheter. Ce = cephalad, F = femur, L = lateral.
infusion, the patient regained full strength and complete return of sensation. Analgesia was provided with oral analgesics. The catheter was discontinued at this time, and the patient was discharged on postoperative day 2.
Discussion This report is the first description of an in vivo contrast study evaluating the potential local anaesthetic distribution after an adductor canal block. This case highlights three important clinical qualities of adductor canal blocks that have not been previously described: 1) clinically significant quadriceps weakness can be a side effect of these nerve blocks; 2) continuous infusions at the adductor canal can result in a clinical picture that varies with duration of infusion; and 3) weakness from an adductor canal nerve block may be related to proximal spread of local anaesthetic to the common femoral nerve, even with small volumes. Continuous adductor canal blocks have been shown in multiple studies to provide analgesia without compromising quadriceps function, although these volunteer studies did not include postsurgical knee replacement subjects.3–5 Despite the absence of reported quadriceps weakness in the literature, this case provides in vivo evidence that a continuous infusion of 0.2% ropivacaine can spread proximally and change the clinical characteristics of the block over time. Jaeger et al. recently reported that those patients who had a continuous adductor canal block after total knee arthroplasty only retained 52% of their baseline quadriceps strength on postoperative day 1.5 This result was dramatically better than those patients who had continuous femoral nerve block; however, because there were no placebo controls for either group, it was impossible to note
Fig. 2. Sequential images of contrast spread from the adductor canal to the common femoral nerve after 2 ml, 3 ml, 4 ml, and 5 ml of contrast. Dark contrast can be visualised tracking from the catheter proximally to the level of the pubis and greater trochanter. P = pubis, GT = greater trochanter, F = femur, white arrow = tip of the catheter.
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the change made by the adductor canal block itself. This patient was unique in that she had no clinical evidence of quadriceps weakness on the day of surgery, but profound quadriceps weakness on the first post-operative day. Isolated profound quadriceps weakness can result from local anaesthetic spread, nerve injury/ compression, surgical trauma, pain, compartment syndrome, or muscle injury. In an effort to determine the cause of her weakness, contrast was slowly injected into the adductor canal. Injection of only 2 ml of contrast into the adductor canal catheter revealed proximal spread to the level of the femoral nerve. The quadriceps weakness was likely due to proximal local anaesthetic spread, as evidenced by the fluoroscopic images of contrast spread and the return of quadriceps strength and femoral nerve distribution sensation 10 h after discontinuation of the 0.2% ropivacaine infusion. This motor and sensory resolution is consistent with the pharmacodynamic profile of 0.2% ropivacaine.11 It is well known that a common femoral nerve blockade will cause motor weakness and sensory blockade.12 This report should serve as a warning to clinicians that local anaesthetic can spread from the adductor canal to the femoral nerve resulting in weakness of the blocked leg. A prior dye study within the adductor canal revealed proximal spread along the adductor canal in cadavers, but nothing reaching to the common femoral nerve.7 Indeed, as several previous studies report intact quadriceps strength after adductor canal nerve blocks in volunteers,1,2 the incidence of proximal local anaesthetic spread causing weakness is likely low. We perform adductor canal nerve blocks for every knee replacement surgery at our institution, and we are presenting the only case of profound quadriceps weakness after continuous adductor canal block over the last 6 months. Nevertheless, this case does highlight the fact that delayed quadriceps weakness can occur with a continuous infusion of local anaesthetic at the adductor canal, and careful monitoring with fall precautions should remain a standard in this patient population. Conflicts of Interest: None. Funding: None.
References 1. Jaeger P, Nielsen ZJ, Henningsen MH, Hilsted KL, Mathiesen O, Dahl JB. Adductor canal block versus femoral
364
2.
3.
4.
5.
6. 7.
8. 9.
10.
11. 12.
nerve block and quadriceps strength: a randomized, doubleblind, placebo-controlled, crossover study in healthy volunteers. Anesthesiology 2013; 118: 409–15. Kwofie MK, Shastri UD, Gadsden JC, Sinha SK, Abrams JH, Xu D, Salviz EA. The effects of ultrasound-guided adductor canal block versus femoral nerve block on quadriceps strength and fall risk: a blinded, randomized trial of volunteers. Reg Anesth Pain Med 2013; 38: 321–5. Hanson NA, Derby RE, Auyong DB, Salinas FV, Delucca C, Nagy R, Yu Z, Slee AE. Ultrasound-guided adductor canal block for arthroscopic medial meniscectomy: a randomized, double-blind trial. Can J Anaesth 2013; 60: 874–80. Jenstrup MT, Jaeger P, Lund J, Fomsgaard JS, Bache S, Mathiesen O, Larsen TK, Dahl JB. Effects of adductor-canalblockade on pain and ambulation after total knee arthroplasty: a randomized study. Acta Anaesthesiol Scand 2012; 56: 357–64. Jaeger P, Zaric D, Fomsgaard JS, Hilsted KL, Bjerregaard J, Gyrn J, Mathiesen O, Larsen TK, Dahl JB. Adductor canal block versus femoral nerve block for analgesia after total knee arthroplasty: a randomized, double-blind study. Reg Anesth Pain Med 2013; 38: 526–32. Davis JJ, Bond TS, Swenson JD. Adductor canal block: more than just the saphenous nerve? Reg Anesth Pain Med 2009; 34: 618–9. Ishiguro S, Yokochi A, Yoshioka K, Asano N, Deguchi A, Iwasaki Y, Sudo A, Maruyama K. Technical communication: anatomy and clinical implications of ultrasound-guided selective femoral nerve block. Anesth Analg 2012; 115: 1467– 70. Tsai PB, Karnwal A, Kakazu C, Tokhner V, Julka IS. Efficacy of an ultrasound-guided subsartorial approach to saphenous nerve block: a case series. Can J Anaesth 2010; 57: 683–8. Saranteas T, Anagnostis G, Paraskeuopoulos T, Koulalis D, Kokkalis Z, Nakou M, Anagnostopoulou S, Kostopanagiotou G. Anatomy and clinical implications of the ultrasound-guided subsartorial saphenous nerve block. Reg Anesth Pain Med 2011; 36: 399–402. Mudumbai SC, Kim TE, Howard SK, Workman JJ, Giori N, Woolson S, Ganaway T, King R, Mariano ER. Continuous adductor canal blocks are superior to continuous femoral nerve blocks in promoting early ambulation after TKA. Clin Orthop Relat Res 2013; Jul 30. doi: 10.1007/s11999-0133197-y Hadzic A. Textbook of regional anesthesia and acute pain management. MaGraw-Hill: 2007. Grant SA, Auyong DB. Ultrasound guided regional anesthesia. New York: Oxford University Press, 2012.
Address: David B. Auyong Department of Anesthesiology Virginia Mason Medical Center 1100 Ninth Avenue, MS: B2-AN Seattle WA 98101 USA e-mail: [email protected]
© 2013 The Acta Anaesthesiologica Scandinavica Foundation. Published by John Wiley & Sons Ltd ACTA ANAESTHESIOLOGICA SCANDINAVICA
doi: 10.1111/aas.12244
Case Report
Delayed quadriceps weakness after continuous adductor canal block for total knee arthroplasty: a case report Christopher Veal, David B. Auyong, Neil A. Hanson, Cindy J. Allen and Wyndam Strodtbeck Anesthesiology, Virginia Mason Medical Center, Seattle, WA, USA
Adductor canal catheters have been shown to improve analgesia while maintaining quadriceps strength after total knee arthroplasty. We describe a patient who underwent total knee arthroplasty that likely had delayed quadriceps weakness as a result of a standard continuous 0.2% ropivacaine infusion at 8 ml/h within the adductor canal. On the day of surgery, the patient was able to stand and ambulate with minimal assistance. On the first post-operative day after surgery, approximately 20 h after starting the ropivacaine infusion, profound weakness of the quadriceps was noted with no ability to stand. Contrast subsequently injected through the adductor canal catheter under
T
he adductor canal block provides analgesia for knee surgery while sparing quadriceps strength.1–3 Intermittent boluses and infusions of local anaesthetics at the adductor canal have been shown to improve post-surgical outcomes after total knee arthroplasty.4,5 It is hypothesised that the proximal spread of local anaesthetic may reach the efferent nerve to the vastus medialis, but usually does not spread to other motor fibres of the femoral nerve, which branch immediately distal to the inguinal ligament.6–9 Quadriceps weakness after total knee arthroplasty is a common phenomenon that can occur with and without the presence of a block.5 As of yet, there have been no formal evaluations of in vivo spread of injectate within the adductor canal. We present a case of delayed profound quadriceps weakness 20 h after continuous infusion of local anaesthetic at the adductor canal following total knee replacement.
Case description Consent: Written consent to publish this case report was obtained directly from the patient described below. A 58-year-old female presented for left total knee arthroplasty. Past medical history was significant for
362 bs_bs_banner
fluoroscopy revealed proximal spread approaching the common femoral nerve with as little as 2 ml of volume. This rare case of profound quadriceps weakness after a continuous adductor canal block reveals that local anaesthetic at the adductor canal can spread in a retrograde fashion towards the common femoral nerve, potentially resulting in quadriceps weakness. Accepted for publication 18 November 2013 © 2013 The Acta Anaesthesiologica Scandinavica Foundation. Published by John Wiley & Sons Ltd
obesity (height = 165 cm, weight = 113.6 kg, body mass index = 44 kg/m2) and obstructive sleep apnoea. A pre-operative adductor canal catheter was placed using in-plane ultrasound guidance at a point midway between the inguinal crease and the superior margin of the patella. The needle was advanced lateral to medial through the vastus medialis muscle and 15 ml 1.5% mepivacaine injected within the potential space to allow advancement of the catheter 1 cm past the tip of the needle.4,5 Surgical anaesthesia was provided by a spinal anaesthetic, and a tourniquet was placed near the site of catheter insertion during the operation. A standard continuous peri-neural infusion was initiated at the end of the procedure with ropivacaine 0.2% at 8 ml/h for post-operative analgesia.5,10 Following routine post-anaesthesia care, the patient was transferred to the hospital floor. Five hours after initiation of the continuous adductor canal infusion, she ambulated 7 m and performed a straight leg raise with excellent analgesia on the day of surgery. However, on post-operative day 1, after approximately 20 h of local anaesthetic infusion, she was unable to perform a straight leg raise or ambulate because of quadriceps weakness. Physical therapy confirmed knee buckling upon standing and inabil-
Quadriceps weakness adductor canal block
ity to ambulate. She continued to report excellent analgesia with a verbal numeric pain score of 0/10. Given the weakness, the peri-neural local anaesthetic infusion was stopped. Reassessment 6 h later revealed persistent quadriceps weakness with continued analgesia. Because of the persistent leg weakness, the patient was consented for a contrast study of the adductor canal catheter. Under fluoroscopy, the tip of the catheter was identified. One millilitre of Isovue M-300 contrast (Bipso GmbH, Singen, Germany) was then slowly injected via the catheter. Fluoroscopy demonstrated retrograde spread of the contrast proximally (Fig. 1). Four more sequential images were captured after additional 1 ml contrast boluses were injected to a total volume of 5 ml (Fig. 2). Fluoroscopic images clearly demonstrated preferential proximal spread towards the common femoral nerve, with minimal distal spread. Ten hours after discontinuation of the local anaesthetic
Fig. 1. Fluoroscopic image of the adductor canal catheter at midfemur. Dark contrast can be visualised preferentially spreading cephalad. Pre = image pre-contrast injection, 1 ml = image after 1 ml of contrast. White arrow = tip of the catheter. Ce = cephalad, F = femur, L = lateral.
infusion, the patient regained full strength and complete return of sensation. Analgesia was provided with oral analgesics. The catheter was discontinued at this time, and the patient was discharged on postoperative day 2.
Discussion This report is the first description of an in vivo contrast study evaluating the potential local anaesthetic distribution after an adductor canal block. This case highlights three important clinical qualities of adductor canal blocks that have not been previously described: 1) clinically significant quadriceps weakness can be a side effect of these nerve blocks; 2) continuous infusions at the adductor canal can result in a clinical picture that varies with duration of infusion; and 3) weakness from an adductor canal nerve block may be related to proximal spread of local anaesthetic to the common femoral nerve, even with small volumes. Continuous adductor canal blocks have been shown in multiple studies to provide analgesia without compromising quadriceps function, although these volunteer studies did not include postsurgical knee replacement subjects.3–5 Despite the absence of reported quadriceps weakness in the literature, this case provides in vivo evidence that a continuous infusion of 0.2% ropivacaine can spread proximally and change the clinical characteristics of the block over time. Jaeger et al. recently reported that those patients who had a continuous adductor canal block after total knee arthroplasty only retained 52% of their baseline quadriceps strength on postoperative day 1.5 This result was dramatically better than those patients who had continuous femoral nerve block; however, because there were no placebo controls for either group, it was impossible to note
Fig. 2. Sequential images of contrast spread from the adductor canal to the common femoral nerve after 2 ml, 3 ml, 4 ml, and 5 ml of contrast. Dark contrast can be visualised tracking from the catheter proximally to the level of the pubis and greater trochanter. P = pubis, GT = greater trochanter, F = femur, white arrow = tip of the catheter.
363
C. Veal et al.
the change made by the adductor canal block itself. This patient was unique in that she had no clinical evidence of quadriceps weakness on the day of surgery, but profound quadriceps weakness on the first post-operative day. Isolated profound quadriceps weakness can result from local anaesthetic spread, nerve injury/ compression, surgical trauma, pain, compartment syndrome, or muscle injury. In an effort to determine the cause of her weakness, contrast was slowly injected into the adductor canal. Injection of only 2 ml of contrast into the adductor canal catheter revealed proximal spread to the level of the femoral nerve. The quadriceps weakness was likely due to proximal local anaesthetic spread, as evidenced by the fluoroscopic images of contrast spread and the return of quadriceps strength and femoral nerve distribution sensation 10 h after discontinuation of the 0.2% ropivacaine infusion. This motor and sensory resolution is consistent with the pharmacodynamic profile of 0.2% ropivacaine.11 It is well known that a common femoral nerve blockade will cause motor weakness and sensory blockade.12 This report should serve as a warning to clinicians that local anaesthetic can spread from the adductor canal to the femoral nerve resulting in weakness of the blocked leg. A prior dye study within the adductor canal revealed proximal spread along the adductor canal in cadavers, but nothing reaching to the common femoral nerve.7 Indeed, as several previous studies report intact quadriceps strength after adductor canal nerve blocks in volunteers,1,2 the incidence of proximal local anaesthetic spread causing weakness is likely low. We perform adductor canal nerve blocks for every knee replacement surgery at our institution, and we are presenting the only case of profound quadriceps weakness after continuous adductor canal block over the last 6 months. Nevertheless, this case does highlight the fact that delayed quadriceps weakness can occur with a continuous infusion of local anaesthetic at the adductor canal, and careful monitoring with fall precautions should remain a standard in this patient population. Conflicts of Interest: None. Funding: None.
References 1. Jaeger P, Nielsen ZJ, Henningsen MH, Hilsted KL, Mathiesen O, Dahl JB. Adductor canal block versus femoral
364
2.
3.
4.
5.
6. 7.
8. 9.
10.
11. 12.
nerve block and quadriceps strength: a randomized, doubleblind, placebo-controlled, crossover study in healthy volunteers. Anesthesiology 2013; 118: 409–15. Kwofie MK, Shastri UD, Gadsden JC, Sinha SK, Abrams JH, Xu D, Salviz EA. The effects of ultrasound-guided adductor canal block versus femoral nerve block on quadriceps strength and fall risk: a blinded, randomized trial of volunteers. Reg Anesth Pain Med 2013; 38: 321–5. Hanson NA, Derby RE, Auyong DB, Salinas FV, Delucca C, Nagy R, Yu Z, Slee AE. Ultrasound-guided adductor canal block for arthroscopic medial meniscectomy: a randomized, double-blind trial. Can J Anaesth 2013; 60: 874–80. Jenstrup MT, Jaeger P, Lund J, Fomsgaard JS, Bache S, Mathiesen O, Larsen TK, Dahl JB. Effects of adductor-canalblockade on pain and ambulation after total knee arthroplasty: a randomized study. Acta Anaesthesiol Scand 2012; 56: 357–64. Jaeger P, Zaric D, Fomsgaard JS, Hilsted KL, Bjerregaard J, Gyrn J, Mathiesen O, Larsen TK, Dahl JB. Adductor canal block versus femoral nerve block for analgesia after total knee arthroplasty: a randomized, double-blind study. Reg Anesth Pain Med 2013; 38: 526–32. Davis JJ, Bond TS, Swenson JD. Adductor canal block: more than just the saphenous nerve? Reg Anesth Pain Med 2009; 34: 618–9. Ishiguro S, Yokochi A, Yoshioka K, Asano N, Deguchi A, Iwasaki Y, Sudo A, Maruyama K. Technical communication: anatomy and clinical implications of ultrasound-guided selective femoral nerve block. Anesth Analg 2012; 115: 1467– 70. Tsai PB, Karnwal A, Kakazu C, Tokhner V, Julka IS. Efficacy of an ultrasound-guided subsartorial approach to saphenous nerve block: a case series. Can J Anaesth 2010; 57: 683–8. Saranteas T, Anagnostis G, Paraskeuopoulos T, Koulalis D, Kokkalis Z, Nakou M, Anagnostopoulou S, Kostopanagiotou G. Anatomy and clinical implications of the ultrasound-guided subsartorial saphenous nerve block. Reg Anesth Pain Med 2011; 36: 399–402. Mudumbai SC, Kim TE, Howard SK, Workman JJ, Giori N, Woolson S, Ganaway T, King R, Mariano ER. Continuous adductor canal blocks are superior to continuous femoral nerve blocks in promoting early ambulation after TKA. Clin Orthop Relat Res 2013; Jul 30. doi: 10.1007/s11999-0133197-y Hadzic A. Textbook of regional anesthesia and acute pain management. MaGraw-Hill: 2007. Grant SA, Auyong DB. Ultrasound guided regional anesthesia. New York: Oxford University Press, 2012.
Address: David B. Auyong Department of Anesthesiology Virginia Mason Medical Center 1100 Ninth Avenue, MS: B2-AN Seattle WA 98101 USA e-mail: [email protected]
