American Society of Regional Anesthesia and Pain Medicine August 2016 - 21
Managing Peripheral Nerve Injury: Understanding the Causes,
Diagnosis, and Management From a Multidisciplinary Standpoint
CLINICAL SCENARIO
A 45-year-old man with a rotator cuff
tear presents for a right shoulder
arthroscopy. The patient has a
history of poorly controlled diabetes
mellitus type 2 with nephropathy and
neuropathy affecting his hands and
feet. An interscalene block is performed
preoperatively with a junior resident.
While needle visualization is difficult
during the block, adequate spread of 20
mL of 0.5% ropivacaine is observed. The
procedure is performed in the lateral
position and is technically difficult as
per the surgeon. On postoperative day
2, the patient complains of weakness
in the shoulder and triceps as well
as tingling in the right thumb. In this
scenario, knowledge of perioperative
nerve injury (PNI) evaluation can help
the anesthesiologist determine
when urgent consultation of a
neurologist is needed.
John-Paul Pozek, MD
Clinical Instructor
Department of Anesthesiology
Thomas Jefferson University
Hospitals
Philadelphia, Pennsylvania
Alison L. Walsh, MD
Clinical Associate Professor
Department of Neurology
Thomas Jefferson University
Hospitals
Philadelphia, Pennsylvania
Section Editor: Jaime Baratta, MD
"Peripheral nerve injury (PNI) after
regional anesthesia is a rare but
distressing complication to both the
patient and the anesthesiologist."
PNI after regional anesthesia
is a rare but distressing
complication to both the patient
and the anesthesiologist. PNIs
can have varying severities and
prognoses, as classified by the
Seddon and Sutherland scales (Figure 1).
Neuropraxia occurs when the myelin sheath is damaged due to
stretching or compression. Prognosis is often good, and symptoms
resolve within weeks. Most lesions associated with peripheral nerve
blocks (PNBs) follow this pattern. Axonotmesis occurs after nerve
crush, toxic injury, or breaching of the fascicle by a needle. Axonal
continuity is lost, as is neural conduction. The prognosis for these
patients is fair, with a prolonged and possibly incomplete recovery.
Gary M. Samms, Esq
Obermayer Rebmann Maxwell &
Hippel LLP
Philadelphia, Pennsylvania
Neurotmesis describes
complete transection of the
nerve. Surgical intervention
is usually required to treat
these patients, and prognosis
is poor.
INCIDENCE
PNI from both neuraxial and
PNB leading to long-term
injury occurs in about 2 to 4 of every 10,000 patients.1 Even with
the implementation of ultrasound-guided regional anesthesia
into daily practice, incidence has remained static.1 Perioperative
neurologic symptoms (PONS) are mostly transient symptoms that
occur after PNB but rarely result in permanent injury. The incidence
of PONS decreases temporally. Risk is 0-2.2% at 3 months,
0-0.8% at 6 months, and 0-0.2% at 12 months, while up to 15%
may have transient paresthesias in the first few days after the
procedure.1
Figure 1: Seddon and Sutherland severity and prognosis classifications.
American Society of Regional Anesthesia and Pain Medicine
2016
21
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