American Society of Regional Anesthesia and Pain Medicine August 2016 - 24
Diagnosis and Treatment: Consulting the Expert
Alison L. Walsh, MD
Clinical Associate Professor, Department of Neurology
Thomas Jefferson University Hospitals
Philadelphia, Pennsylvania
WHAT ARE THE INDICATIONS FOR EARLY NEUROLOGIC
CONSULTATION IN THE SETTING OF SUSPECTED PERIPHERAL
NERVE INJURY (PNI)?
Early neurologic consultation should be considered in patients
who develop a complete or severe injury, functional deficits
related to the injury, or rapidly progressive neurological
deficits.
WHAT IS THE UTILITY OF ELECTRODIAGNOSTIC (EDX)
STUDIES OF SUSPECTED PNI? WHEN ARE THESE STUDIES
INDICATED?
EDX studies can localize the distribution of injury and assess
characteristics of the injury severity. They also help aid
in prognostication. Sensory symptoms present in typical
compressive sites may not need EDX.
I would recommend EDX in cases of injury in areas distinct
from the surgical or anesthetic site, diffuse neurologic
symptoms, severe symptoms, and patients who do not
improve symptomatically over time. In cases of nerve injury
known to be secondary to the procedure, I might consider
immediate postoperative evaluation to gauge the degree of
injury.
WHEN IS IT APPROPRIATE TO OBSERVE AND REASSURE A
PATIENT?
Observe and reassure the patient in the case of mild sensory
symptoms, symptoms in a common site of compression likely
related to surgery, and improving/resolving symptoms. Most
postoperative nerve injuries are self-limited and monophasic
with a good potential for recovery.
indicated, as the patient has both sensory and motor symptoms.
With improving symptoms, the patient underwent electrodiagnostic
studies 3 weeks after the procedure and followed up with a
neurologist until symptoms resolved.
REFERENCES
1.
24
2
Neal JM, Barrington MJ, Brull R, et al. The second ASRA practice advisory
on neurologic complications associated with regional anesthesia and pain
medicine. Reg Anesth Pain Med. 2015;40:401-430.
WHAT ARE THE RECOMMENDATIONS FOR PATIENT FOLLOWUP AFTER A PNI?
Patient follow-up depends on the patient's symptoms. In the
case of severe or persistent symptoms, monthly evaluation is
recommended. However, if symptoms are purely sensory and
resolving, the patient should be followed up with as needed.
HOW WOULD YOU NONSURGICALLY MANAGE A PATIENT WITH
PNI?
Nonsurgical, supportive care includes physical therapy,
occupational therapy, and pain management.
AT WHAT POINT WOULD A NEUROLOGIST RECOMMEND THIS
PATIENT TO PAIN MANAGEMENT?
Pain is often undertreated and needs to be addressed
adequately. Depending on the patient, after I exhaust my
typical arsenal of medications for neuropathic pain, I will refer
to a pain management specialist who can offer additional
medication advice and potential interventions for pain relief.
WHEN DO YOU REFER TO A PERIPHERAL NERVE SURGEON?
When the patient has severe symptoms with poor recovery,
surgical treatment is indicated.
FINALLY, DO YOU HAVE ANY RECOMMENDATIONS REGARDING
DOCUMENTATION DURING THE PERIOPERATIVE PERIOD IN A
PATIENT WITH SUSPECTED PNI?
I recommend notations as to the extent patients experience
pain or paresthesias during administration of anesthesia.
Increased symptoms are associated with development of PNI.
Once sedation has subsided and the patient is lucid, a thorough
neurologic exam is indicated.
2.
Steinfeldt T, Poeschl S, Nimphius W, et al. Forced needle advancement during
needle-nerve contact in a porcine model: histological outcome. Anesth Analg.
2011;113:417-420.
3.
Brull R, Hadzic A, Reina MA, et al. Pathophysiology and etiology of nerve injury
following peripheral nerve blockade. Reg Anesth Pain Med. 2015;40:479-490.
4.
Hogan QH. Pathophysiology of peripheral nerve injury during regional
anesthesia. Reg Anesth Pain Med. 2008;33:435-441.
5.
Partridge BL. The effects of local anesthetics and epinephrine on rat sciatic
nerve blood flow. Anesthesiology. 1991;75:243-250.
American Society of Regional Anesthesia and Pain Medicine
2016
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