American Society of Regional Anesthesia and Pain Medicine August 2016 - 23
INFLAMMATION
Postoperative inflammatory neuropathy is a severe neuropathy that
can occur without documented neural trauma.8 Presentation may
be focal, multifocal, or diffuse pain and weakness that is either
spatially or temporally remote from the surgery.8 This neuropathy
is due to a lymphocytic inflammatory reaction within neural tissue.
While the cause is unclear, it is likely due to a combination of
postoperative inflammatory response, genetics, and mechanical
trauma.8 Because of the unique pathophysiology of this process,
prompt neurologic evaluation is indicated to provide the best
treatment for these patients.
Nerve conduction and electromyelographic studies may not be
useful in diagnosis, but magnetic resonance imaging of peripheral
nerves shows an abnormal signal in the distribution of the affected
nerve.8 Biopsy of the nerve may help expedite diagnosis and
direct treatment. Immunomodulators have been efficacious in this
population, but there have been reports of symptom improvements
in patients without treatment.8
discussed earlier, avoidance of intrafascicular injection of local
anesthetic can decrease risk. Interestingly, a study by Bigeleisen
demonstrated that intraneural injection in healthy patients did not
result in neuropathy.9 However, the current ASRA practice advisory
on neurologic complications does not recommend intentional
intraneural injections.1
MULTIDISCIPLINARY MANAGEMENT
Management of a PNI is a multidisciplinary undertaking (Figure 3).
To gain a greater understanding of management in patients with
PNI, we spoke with a neurologist at our institution, Dr Alison Walsh
(see page 24). Dealing with an unexpected or poor outcome can
be quite a distressing time, and identifying what you can or cannot
say, proper documentation, and when to refer to risk management
is often confusing. We consulted with Gary Samms, Esq, a
malpractice attorney in Philadelphia, for some practical advice (see
page 25).
ETIOLOGY OF PNI
Increased risk for PNI in the perioperative period is influenced by
multiple factors including the anesthetic plan, surgical decision
making, and the patient's preexisting comorbidities (Figure 2). As
CLINICAL SCENARIO REVISITED
The patient had multiple risk factors for PNI, including patient-,
surgery-, and anesthetic-specific factors. With neuropathy present
within the distribution of the PNB, we must rule out surgical causes,
coagulopathy, ongoing compression, and possible compartment
syndrome. If these are not present, neurologic evaluation is
Figure 2: Factors influencing risk for PNI.
Figure 3: Management of PNI algorithm.
American Society of Regional Anesthesia and Pain Medicine
2016
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