J Clin Monit Comput DOI 10.1007/s10877-015-9681-z
ORIGINAL RESEARCH
Permanent upper trunk plexopathy after interscalene brachial plexus block Merce Avellanet1 • Xavier Sala-Blanch2 • Lidia Rodrigo1 • Miguel A. Gonzalez-Viejo3
Received: 4 November 2014 / Accepted: 27 February 2015 Springer Science+Business Media New York 2015
Abstract Interscalene brachial plexus block (IBPB) has been widely used in shoulder surgical procedures. The incidence of postoperative neural injury has been estimated to be as high as 3 %. We report a long-term neurologic deficit after a nerve stimulator assisted brachial plexus block. A 55 year-old male, with right shoulder impingement syndrome was scheduled for elective surgery. The patient was given an oral dose of 10 mg of diazepam prior to the nerve stimulator assisted brachial plexus block. The patient immediately complained, as soon as the needle was placed in the interscalene area, of a sharp pain in his right arm and he was sedated further. Twenty-four hours later, the patient complained of severe shoulder and arm pain that required an increased dose of analgesics. Severe peri-scapular atrophy developed over the following days. Electromyography studies revealed an upper trunk plexus injury with severe denervation of the supraspinatus, infraspinatus and deltoid muscles together with a moderate denervation of the biceps brachii muscle. Chest X-rays showed a diaphragmatic palsy which was not present post operatively. Pulmonary function tests were also affected. Phrenic nerve
This article was presented at Annual Assembly of the American Academy of Physical and Rehabilitation Medicine, Washington (USA) 3–6 October 2013. & Merce Avellanet [email protected] 1
Physical Medicine and Rehabilitation Department, Hospital Nostra Sra. Meritxell, Fiter i Rossell 1-13, Escaldes AD 700, Andorra
2
Anaesthesiology Department, Hospital Clinic, Universitat de Barcelona, Barcelona, Spain
3
Physical Medicine and Rehabilitation, Hospital UniversitariValld’Hebron, Barcelona, Spain
paralysis was still present 18 months after the block as was dysfunction of the brachial plexus resulting in an inability to perform flexion, abduction and external rotation of the right shoulder. Severe brachial plexopathy was probably due to a local anesthetic having been administrated through the perineurium and into the nerve fascicles. Severe brachial plexopathy is an uncommon but catastrophic complication of IBPB. We propose a clinical algorithm using ultrasound guidance during nerve blocks as a safer technique of regional anesthesia. Keywords Brachial plexus block Interscalene block Neurostimulation Nerve injury Intraneural injection Ultrasound
1 Introduction The Interscalene brachial plexus block (IBPB) is the most commonly used method of anaesthesia and analgesia in shoulder surgery [1, 2]. Although it is usually considered a safe block, the risk of complications has been reported from between 3 to 10 % [3, 4]. Even though the number of moderate to severe complications is low, they present a significant impairment to the patient [5–8]. Many reasons have been suggested for these types of complications, but it was the intraneural injection which was highlighted as the main cause of severe complications [9]. Although the intraneural injection is not usually associated with ongoing nerve damage in many cases, the degree of damage will depend on the nerve structure affected, the brachial plexus being of particular importance. There are no clinical algorithms in place that can assist in monitoring how peripheral nerve blocks are performed in order to prevent neural injuries [10].
123
J Clin Monit Comput
We report the case of a patient who suffered a severe neurological deficit after an IBPB. We strongly believe that such a severe deficit was due to an intraneural with intrafascicular injection of a local anaesthetic (LA) drug. We propose a clinical algorithm in order to assist with the assessment and prevention of similar complications.
2 Case report Surgery was advised for a 55-year-old right-handed man, with right shoulder impingement syndrome who had shown no improvement after 12 months of conservative treatment. Shoulder pain was preventing any sporting activity involving the right upper limb and some activities of daily living (ADL) were also affected, which ultimately led to surgery. In the preoperative anaesthetic evaluation, the patient expressed his preference for general anaesthesia and he signed a generic and unspecific consent form. Before arriving at the operation room, the patient was sedated with diazepam, 10 mg per os (p.o.) and the anaesthesiologist conducted an IBPB guided by nerve stimulation on the right antero-lateral cervical side. We do not have details of the type of needle (short-bevel or long-bevel needle), nerve stimulator device nor about the neurostimulation technique applied (current intensity, motor response characteristics, etc.). Furthermore, the patient clearly remembered feeling an intense sharp pain in his arm, after which he was immediately sedated. This procedure was performed without an ultrasonography guidance. The first 24 h following the operation, the patient was medicated intravenously (dexketoprofen 25 mg every 8 h and 1 g paracetamol every 8 h) and did not complain of any pain. Twenty-four hours after the procedure he was discharged and the same medication was prescribed p.o. However, he began to complain about severe burning pain in his shoulder and right arm. Pain continued over the next few days and he required a progressive increase in analgesic medication, including oxycodone that partially minimized the pain. Within ten days of surgery severe periscapsular atrophy developed (Fig. 1a). Supraspinatus, infraspinatus and deltoid strength were rated 0/5 whereas biceps brachii was 2/5. Initially, it was thought to the problem was a brachial neuritis (like a Parsonnage Turner syndrome). Electromyography was performed three weeks later, showing an upper trunk plexus injury (C5, C6 partially C7), with severe denervation of the supraspinatus, infraspinatus, deltoid, and moderate denervation in biceps brachii. Electrodiagnostic testing of the peripheral nervous system is an adjunct to the history, physical examination, and other laboratory studies in the overall evaluation of the peripheral nervous system. They are not recommended
123
Fig. 1 Clinical findings, a clinical atrophy in shoulder girdle, b diaphragmatic palsy in chest X-ray
before three weeks after injury. An MRI of cervical and shoulder regions was performed to rule out other causes of nerve compression. Additionally, the patient complained of dyspnea. Pulmonary function was also affected (forced vital capacity, FVC, 60 %) due to partial diaphragmatic palsy, visible on radiological exam (Fig. 1b). An intraneural injection with massive intrafascicular infiltration during IBPB was suspected. One year later after intensive rehabilitation functional disability persisted with an inability to flex, abduct and externally rotate the shoulder. FVC was still 60 %.
3 Comment This case illustrates a severe complication of an IBPB. There is a strong probability that the intraneural injection together with massive intrafascicular infiltration of a LA solution at the anterior rami of C5–C6 nerve roots played a major role in the neural injury described. The onset of
J Clin Monit Comput
neurostimulation devices should not be used to locate neural structures but as a means of increasing safety when performing a peripheral nerve block. When motor responses are \0.5 mA, the injection of LA solutions should be avoided. Injection pressure monitoring (w [15) has been studied in cadaver models, comparing when the needle is intraneural [9] and when the needle lies close to the nerve root but does not puncture it [16]. These studies demonstrated that nerve block pressure injection monitoring is a useful tool in order to prevent an intrafascicular injection in noncompliant neural structures like the brachial plexus. It is also important to control the spread of the LA around the nerve. Needle choice is another issue as it can also play a role in peripheral nerve injury [17]. The perineurium is a resistant tissue unlikely to be penetrated by a blunt shortbevel needle. However, when intrafascicular penetration occurs, short-bevel needles are associated with more severe and longer lasting injuries [11]. Figure 2 describes a clinical algorithm when performing a peripheral nerve block under ultrasound guidance [14]. We are not able to prove conclusively that had ultrasound
Advance needle with NRS (0.1 mseg, 2 Hz, 0.5 mA)
US: Limits of the nerve/plexus well defined Yes No US: Relaonship between p’s needle and nerve clear Yes Paent: No Pain / No Paresthesia
Yes and persistent
No NRS: No motor response or ≥ 0.5 mA
Stop and re-evaluate
paresthesia following the injection of the LA solution, clinical observations (myoatrophy in shoulder girdle) and electrophysiological studies both support this evidence. Other causes (i.e. injection of alcohol containing antiseptic solution,…) may have played a role in this injury but are very unlikely. It should be noted that a peripheral nerve stimulation of brachial plexus nerves was the method used to locate the brachial plexus. Although there was no documentation of the nerve stimulation parameters used (frequency, stimulus duration and current output), paresthesia and dysesthesia in relation to the injection of LA solution was well documented. It has been documented that intraneural injections do not necessarily result in permanent injury because the simple penetration of the epineurium does not always produce neural injury [11]. Nerve fibers are organized in nerves fascicles which are surrounded by a tough and resistant sheath, the perineurium. Embedded within stromal tissue, these fascicles are surrounded by the epineurium. We believe that the fascicles have been massively injuried and subsequently caused the damage to nerve fascicles. Peripheral nerve blocks are usually safe and have beneficial effects in providing anaesthesia and analgesia in shoulder surgery. The procedure has been extensively reported [1, 2]. However, the incidence of complications of these blocks should not be underestimated. In a comprehensive review, the rate of neuropathy associated with IBPB was 2.84:100 (95 % CI 1.33–5.98:100) but only one case of permanent neuropathy was reported among 16 studies of neurological complications after peripheral nerve blocks [4]. Following the increased use of ultrasoundguided techniques in regional anaesthesia, there are several prospective studies that report a reduction in the incidence of postoperative neurological deficits [12, 13]. Other reports describe an increased incidence of complications of 10 % in the early postoperative period, 3.3 % of which occur in the 18-months period after surgery. The methodology used in these latter studies remains controversial [10, 14]. The interscalene brachial plexus has a compact neural structure (monofascicular characteristics) that predisposes the patient to an increased risk of injury when an intraneural injection occurs. Traditionally, it is recommended that nerve block techniques should be performed in a patient who is conscious in order to help with the early recognition of adverse effects. Two main techniques are used to guide the IBPB: nerve stimulation and ultrasound. The poor predictive accuracy of nerve stimulation in helping locate the sciatic nerve is well recognized, but the predictive value is greater at lower intensities (\0.3 mA) [10]. Clinical studies with neurostimulation have failed to demonstrate motor response at a current intensity of 0.5 mA in 25 % of cases [15]. Therefore, we believe that
Yes (< 0.5 mA)
Yes OP: No ressitance to injecon
High (≥15 psi)
Low (< 15 psi) US: Assess LA spread and adequate distribuon
Swelling or maldistribuon
Yes
Paent: Clinical evaluaon of the block onset Block adequate for surgery Start Surgery
Fig. 2 Clinical.algorithm for ultrasound guided Interscalene brachial plexus block (modified from Sala-Blanch et al.) [14]. NRS: NeuRoStimulation, US: UltraSound, LA: Local Anesthaesic
123
J Clin Monit Comput
guidance been used it would have prevented this severe adverse event. However, in this case, reasonable preventative measures were not used. In conclusion, we believe that case reports like the one we describe underline the importance of rigorous technical procedures. By applying the current knowledge globally and the available evidence to the routine practice of regional anesthesia, we are convinced that a high success rate of nerve blocks would be associated with a decrease in complications, although they cannot be eliminated completely.
Conflict of interest If no conflict exists, authors should state: The authors declare that they have no conflict of interest.
References 1. Lin E, Choi J, Hadzic A. Peripheral nerve blocks for outpatient surgery: evidence-based indications. Curr Opin Anaesthesiol. 2013;26(4):467–74. 2. Moore DD, Maerz T, Anderson K. Shoulder surgeons’ perceptions of interscalene nerve blocks and a review of complications rates in the literature. Phys Sports Med. 2013;41(3):77–84. 3. Bilbao Ares A, Sabate´ A, Porteiro L, Iba´n˜ez B, Koo M, Pi A. Neurological complications associated with ultrasound-guided interscalene and supraclavicular block in elective surgery of the shoulder and arm. Prospective observational study in a university hospital. Rev Esp Anestesiol Reanim. 2013;60(7):384–91. 4. Brull R, McCartney CJ, Chan VW, El-Beheiry H. Neurological complications after regional anesthesia: contemporary estimates of risk. Anesth Analg. 2007;104(4):965–74. 5. Robaux S, Bouaziz H, Boisseau N, Raucoules-Aime´ M, Laxenaire MC. Persistent phrenic nerve paralysis following interscalene brachial plexus block. Anesthesiology. 2001;95(6):1519–21. 6. Ediale KR, Myung CR, Neuman GG. Prolonged hemidiaphragmatic paralysis following interscalene brachial plexus block. J Clin Anesth. 2004;16(8):573–5.
123
7. Borgeat A, Ekatodramis G, Kalberer F, Benz C. Acute and nonacute complications associated with interscalene block and shoulder surgery: a prospective study. Anesthesiology. 2001; 95(4):875–80. 8. Benumof JL. Permanent loss of cervical spinal cord function associated with interscalene block performed under general anesthesia. Anesthesiology. 2000;93(6):1541–4. 9. Orebaugh SL, Mukalel JJ, Krediet AC, Weimer J, Filip P, McFadden K, Bigeleisen PE. Brachial plexus root injection in a human cadaver model: injectate distribution and effects on the neuraxis. Reg Anesth Pain Med. 2012;37(5):525–9. 10. Sala-Blanch X, Vandepitte C, Laur JJ, Horan P, Xu D, Reina MA, Karmakar MK, Clark TB, Hadzic A. A practical review of perineural versus intraneural injections: a call for standard nomenclature. Int Anesthesiol Clin. 2011;49(4):1–12. 11. Jeng CL, Rosenblatt MA. Intraneural injections and regional anesthesia: the known and the unknown. Minerva Anestesiol. 2011;77(1):54–8. 12. Barrington MJ, Watts SA, Gledhill SR, Thomas RD, Said SA, Snyder GL, Tay VS, Jamrozik K. Preliminary results of the Australasian Regional Anaesthesia Collaboration: a prospective audit of more than 7000 peripheral nerve and plexus blocks for neurologic and other complications. Reg Anesth Pain Med. 2009;34(6):534–41. 13. Sviggum HP, Jacob AK, Mantilla CB, Schroeder DR, Sperling JW, Hebl JR. Perioperative nerve injury after total shoulder arthroplasty: assessment of risk after regional anesthesia. Reg Anesth Pain Med. 2012;37(5):490–4. 14. Sala-Blanch X, Lo´pez AM, Vandepitte C. Safety algorithms for ultrasound guided blocks: the next challenge. Rev Esp Anestesiol Reanim. 2015;62(2):116–7. 15. Bollini CA, Urmey WF, Vascello L, Cacheiro F. Relationship between evoked motor response and sensory paresthesia in interscalene brachial plexus block. Reg Anesth Pain Med. 2003;28(5):384–8. 16. Gadsden JC, Choi JJ, Lin E, Robinson A. Opening injection pressure consistently detects needle-nerve contact during ultrasound-guided interscalene brachial plexus block. Anesthesiology. 2014;120(5):1246–53. 17. Jeng CL, Torrillo TM, Rosenblatt MA. Complications of peripheral nerve blocks. Br J Anesth. 2010;105(S1):97–107.
ORIGINAL RESEARCH
Permanent upper trunk plexopathy after interscalene brachial plexus block Merce Avellanet1 • Xavier Sala-Blanch2 • Lidia Rodrigo1 • Miguel A. Gonzalez-Viejo3
Received: 4 November 2014 / Accepted: 27 February 2015 Springer Science+Business Media New York 2015
Abstract Interscalene brachial plexus block (IBPB) has been widely used in shoulder surgical procedures. The incidence of postoperative neural injury has been estimated to be as high as 3 %. We report a long-term neurologic deficit after a nerve stimulator assisted brachial plexus block. A 55 year-old male, with right shoulder impingement syndrome was scheduled for elective surgery. The patient was given an oral dose of 10 mg of diazepam prior to the nerve stimulator assisted brachial plexus block. The patient immediately complained, as soon as the needle was placed in the interscalene area, of a sharp pain in his right arm and he was sedated further. Twenty-four hours later, the patient complained of severe shoulder and arm pain that required an increased dose of analgesics. Severe peri-scapular atrophy developed over the following days. Electromyography studies revealed an upper trunk plexus injury with severe denervation of the supraspinatus, infraspinatus and deltoid muscles together with a moderate denervation of the biceps brachii muscle. Chest X-rays showed a diaphragmatic palsy which was not present post operatively. Pulmonary function tests were also affected. Phrenic nerve
This article was presented at Annual Assembly of the American Academy of Physical and Rehabilitation Medicine, Washington (USA) 3–6 October 2013. & Merce Avellanet [email protected] 1
Physical Medicine and Rehabilitation Department, Hospital Nostra Sra. Meritxell, Fiter i Rossell 1-13, Escaldes AD 700, Andorra
2
Anaesthesiology Department, Hospital Clinic, Universitat de Barcelona, Barcelona, Spain
3
Physical Medicine and Rehabilitation, Hospital UniversitariValld’Hebron, Barcelona, Spain
paralysis was still present 18 months after the block as was dysfunction of the brachial plexus resulting in an inability to perform flexion, abduction and external rotation of the right shoulder. Severe brachial plexopathy was probably due to a local anesthetic having been administrated through the perineurium and into the nerve fascicles. Severe brachial plexopathy is an uncommon but catastrophic complication of IBPB. We propose a clinical algorithm using ultrasound guidance during nerve blocks as a safer technique of regional anesthesia. Keywords Brachial plexus block Interscalene block Neurostimulation Nerve injury Intraneural injection Ultrasound
1 Introduction The Interscalene brachial plexus block (IBPB) is the most commonly used method of anaesthesia and analgesia in shoulder surgery [1, 2]. Although it is usually considered a safe block, the risk of complications has been reported from between 3 to 10 % [3, 4]. Even though the number of moderate to severe complications is low, they present a significant impairment to the patient [5–8]. Many reasons have been suggested for these types of complications, but it was the intraneural injection which was highlighted as the main cause of severe complications [9]. Although the intraneural injection is not usually associated with ongoing nerve damage in many cases, the degree of damage will depend on the nerve structure affected, the brachial plexus being of particular importance. There are no clinical algorithms in place that can assist in monitoring how peripheral nerve blocks are performed in order to prevent neural injuries [10].
123
J Clin Monit Comput
We report the case of a patient who suffered a severe neurological deficit after an IBPB. We strongly believe that such a severe deficit was due to an intraneural with intrafascicular injection of a local anaesthetic (LA) drug. We propose a clinical algorithm in order to assist with the assessment and prevention of similar complications.
2 Case report Surgery was advised for a 55-year-old right-handed man, with right shoulder impingement syndrome who had shown no improvement after 12 months of conservative treatment. Shoulder pain was preventing any sporting activity involving the right upper limb and some activities of daily living (ADL) were also affected, which ultimately led to surgery. In the preoperative anaesthetic evaluation, the patient expressed his preference for general anaesthesia and he signed a generic and unspecific consent form. Before arriving at the operation room, the patient was sedated with diazepam, 10 mg per os (p.o.) and the anaesthesiologist conducted an IBPB guided by nerve stimulation on the right antero-lateral cervical side. We do not have details of the type of needle (short-bevel or long-bevel needle), nerve stimulator device nor about the neurostimulation technique applied (current intensity, motor response characteristics, etc.). Furthermore, the patient clearly remembered feeling an intense sharp pain in his arm, after which he was immediately sedated. This procedure was performed without an ultrasonography guidance. The first 24 h following the operation, the patient was medicated intravenously (dexketoprofen 25 mg every 8 h and 1 g paracetamol every 8 h) and did not complain of any pain. Twenty-four hours after the procedure he was discharged and the same medication was prescribed p.o. However, he began to complain about severe burning pain in his shoulder and right arm. Pain continued over the next few days and he required a progressive increase in analgesic medication, including oxycodone that partially minimized the pain. Within ten days of surgery severe periscapsular atrophy developed (Fig. 1a). Supraspinatus, infraspinatus and deltoid strength were rated 0/5 whereas biceps brachii was 2/5. Initially, it was thought to the problem was a brachial neuritis (like a Parsonnage Turner syndrome). Electromyography was performed three weeks later, showing an upper trunk plexus injury (C5, C6 partially C7), with severe denervation of the supraspinatus, infraspinatus, deltoid, and moderate denervation in biceps brachii. Electrodiagnostic testing of the peripheral nervous system is an adjunct to the history, physical examination, and other laboratory studies in the overall evaluation of the peripheral nervous system. They are not recommended
123
Fig. 1 Clinical findings, a clinical atrophy in shoulder girdle, b diaphragmatic palsy in chest X-ray
before three weeks after injury. An MRI of cervical and shoulder regions was performed to rule out other causes of nerve compression. Additionally, the patient complained of dyspnea. Pulmonary function was also affected (forced vital capacity, FVC, 60 %) due to partial diaphragmatic palsy, visible on radiological exam (Fig. 1b). An intraneural injection with massive intrafascicular infiltration during IBPB was suspected. One year later after intensive rehabilitation functional disability persisted with an inability to flex, abduct and externally rotate the shoulder. FVC was still 60 %.
3 Comment This case illustrates a severe complication of an IBPB. There is a strong probability that the intraneural injection together with massive intrafascicular infiltration of a LA solution at the anterior rami of C5–C6 nerve roots played a major role in the neural injury described. The onset of
J Clin Monit Comput
neurostimulation devices should not be used to locate neural structures but as a means of increasing safety when performing a peripheral nerve block. When motor responses are \0.5 mA, the injection of LA solutions should be avoided. Injection pressure monitoring (w [15) has been studied in cadaver models, comparing when the needle is intraneural [9] and when the needle lies close to the nerve root but does not puncture it [16]. These studies demonstrated that nerve block pressure injection monitoring is a useful tool in order to prevent an intrafascicular injection in noncompliant neural structures like the brachial plexus. It is also important to control the spread of the LA around the nerve. Needle choice is another issue as it can also play a role in peripheral nerve injury [17]. The perineurium is a resistant tissue unlikely to be penetrated by a blunt shortbevel needle. However, when intrafascicular penetration occurs, short-bevel needles are associated with more severe and longer lasting injuries [11]. Figure 2 describes a clinical algorithm when performing a peripheral nerve block under ultrasound guidance [14]. We are not able to prove conclusively that had ultrasound
Advance needle with NRS (0.1 mseg, 2 Hz, 0.5 mA)
US: Limits of the nerve/plexus well defined Yes No US: Relaonship between p’s needle and nerve clear Yes Paent: No Pain / No Paresthesia
Yes and persistent
No NRS: No motor response or ≥ 0.5 mA
Stop and re-evaluate
paresthesia following the injection of the LA solution, clinical observations (myoatrophy in shoulder girdle) and electrophysiological studies both support this evidence. Other causes (i.e. injection of alcohol containing antiseptic solution,…) may have played a role in this injury but are very unlikely. It should be noted that a peripheral nerve stimulation of brachial plexus nerves was the method used to locate the brachial plexus. Although there was no documentation of the nerve stimulation parameters used (frequency, stimulus duration and current output), paresthesia and dysesthesia in relation to the injection of LA solution was well documented. It has been documented that intraneural injections do not necessarily result in permanent injury because the simple penetration of the epineurium does not always produce neural injury [11]. Nerve fibers are organized in nerves fascicles which are surrounded by a tough and resistant sheath, the perineurium. Embedded within stromal tissue, these fascicles are surrounded by the epineurium. We believe that the fascicles have been massively injuried and subsequently caused the damage to nerve fascicles. Peripheral nerve blocks are usually safe and have beneficial effects in providing anaesthesia and analgesia in shoulder surgery. The procedure has been extensively reported [1, 2]. However, the incidence of complications of these blocks should not be underestimated. In a comprehensive review, the rate of neuropathy associated with IBPB was 2.84:100 (95 % CI 1.33–5.98:100) but only one case of permanent neuropathy was reported among 16 studies of neurological complications after peripheral nerve blocks [4]. Following the increased use of ultrasoundguided techniques in regional anaesthesia, there are several prospective studies that report a reduction in the incidence of postoperative neurological deficits [12, 13]. Other reports describe an increased incidence of complications of 10 % in the early postoperative period, 3.3 % of which occur in the 18-months period after surgery. The methodology used in these latter studies remains controversial [10, 14]. The interscalene brachial plexus has a compact neural structure (monofascicular characteristics) that predisposes the patient to an increased risk of injury when an intraneural injection occurs. Traditionally, it is recommended that nerve block techniques should be performed in a patient who is conscious in order to help with the early recognition of adverse effects. Two main techniques are used to guide the IBPB: nerve stimulation and ultrasound. The poor predictive accuracy of nerve stimulation in helping locate the sciatic nerve is well recognized, but the predictive value is greater at lower intensities (\0.3 mA) [10]. Clinical studies with neurostimulation have failed to demonstrate motor response at a current intensity of 0.5 mA in 25 % of cases [15]. Therefore, we believe that
Yes (< 0.5 mA)
Yes OP: No ressitance to injecon
High (≥15 psi)
Low (< 15 psi) US: Assess LA spread and adequate distribuon
Swelling or maldistribuon
Yes
Paent: Clinical evaluaon of the block onset Block adequate for surgery Start Surgery
Fig. 2 Clinical.algorithm for ultrasound guided Interscalene brachial plexus block (modified from Sala-Blanch et al.) [14]. NRS: NeuRoStimulation, US: UltraSound, LA: Local Anesthaesic
123
J Clin Monit Comput
guidance been used it would have prevented this severe adverse event. However, in this case, reasonable preventative measures were not used. In conclusion, we believe that case reports like the one we describe underline the importance of rigorous technical procedures. By applying the current knowledge globally and the available evidence to the routine practice of regional anesthesia, we are convinced that a high success rate of nerve blocks would be associated with a decrease in complications, although they cannot be eliminated completely.
Conflict of interest If no conflict exists, authors should state: The authors declare that they have no conflict of interest.
References 1. Lin E, Choi J, Hadzic A. Peripheral nerve blocks for outpatient surgery: evidence-based indications. Curr Opin Anaesthesiol. 2013;26(4):467–74. 2. Moore DD, Maerz T, Anderson K. Shoulder surgeons’ perceptions of interscalene nerve blocks and a review of complications rates in the literature. Phys Sports Med. 2013;41(3):77–84. 3. Bilbao Ares A, Sabate´ A, Porteiro L, Iba´n˜ez B, Koo M, Pi A. Neurological complications associated with ultrasound-guided interscalene and supraclavicular block in elective surgery of the shoulder and arm. Prospective observational study in a university hospital. Rev Esp Anestesiol Reanim. 2013;60(7):384–91. 4. Brull R, McCartney CJ, Chan VW, El-Beheiry H. Neurological complications after regional anesthesia: contemporary estimates of risk. Anesth Analg. 2007;104(4):965–74. 5. Robaux S, Bouaziz H, Boisseau N, Raucoules-Aime´ M, Laxenaire MC. Persistent phrenic nerve paralysis following interscalene brachial plexus block. Anesthesiology. 2001;95(6):1519–21. 6. Ediale KR, Myung CR, Neuman GG. Prolonged hemidiaphragmatic paralysis following interscalene brachial plexus block. J Clin Anesth. 2004;16(8):573–5.
123
7. Borgeat A, Ekatodramis G, Kalberer F, Benz C. Acute and nonacute complications associated with interscalene block and shoulder surgery: a prospective study. Anesthesiology. 2001; 95(4):875–80. 8. Benumof JL. Permanent loss of cervical spinal cord function associated with interscalene block performed under general anesthesia. Anesthesiology. 2000;93(6):1541–4. 9. Orebaugh SL, Mukalel JJ, Krediet AC, Weimer J, Filip P, McFadden K, Bigeleisen PE. Brachial plexus root injection in a human cadaver model: injectate distribution and effects on the neuraxis. Reg Anesth Pain Med. 2012;37(5):525–9. 10. Sala-Blanch X, Vandepitte C, Laur JJ, Horan P, Xu D, Reina MA, Karmakar MK, Clark TB, Hadzic A. A practical review of perineural versus intraneural injections: a call for standard nomenclature. Int Anesthesiol Clin. 2011;49(4):1–12. 11. Jeng CL, Rosenblatt MA. Intraneural injections and regional anesthesia: the known and the unknown. Minerva Anestesiol. 2011;77(1):54–8. 12. Barrington MJ, Watts SA, Gledhill SR, Thomas RD, Said SA, Snyder GL, Tay VS, Jamrozik K. Preliminary results of the Australasian Regional Anaesthesia Collaboration: a prospective audit of more than 7000 peripheral nerve and plexus blocks for neurologic and other complications. Reg Anesth Pain Med. 2009;34(6):534–41. 13. Sviggum HP, Jacob AK, Mantilla CB, Schroeder DR, Sperling JW, Hebl JR. Perioperative nerve injury after total shoulder arthroplasty: assessment of risk after regional anesthesia. Reg Anesth Pain Med. 2012;37(5):490–4. 14. Sala-Blanch X, Lo´pez AM, Vandepitte C. Safety algorithms for ultrasound guided blocks: the next challenge. Rev Esp Anestesiol Reanim. 2015;62(2):116–7. 15. Bollini CA, Urmey WF, Vascello L, Cacheiro F. Relationship between evoked motor response and sensory paresthesia in interscalene brachial plexus block. Reg Anesth Pain Med. 2003;28(5):384–8. 16. Gadsden JC, Choi JJ, Lin E, Robinson A. Opening injection pressure consistently detects needle-nerve contact during ultrasound-guided interscalene brachial plexus block. Anesthesiology. 2014;120(5):1246–53. 17. Jeng CL, Torrillo TM, Rosenblatt MA. Complications of peripheral nerve blocks. Br J Anesth. 2010;105(S1):97–107.
