Permanent upper trunk plexopathy after interscalene brachial plexus block

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 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.

Adjacent intact nociceptive neurons drive the acute outburst of pain following peripheral axotomy

“…We next examined the neurophysiologic mechanisms that may underlie the quick onset of pain after L5 SNT (dissecting scissors cut). Recent microneurography studies in patients suggested that development of SA and ectopic discharge in a subpopulation of DRG neurons after nerve injury might underlie spontaneous pain 1,2 . By conducting highly sensitive ex vivo electrophysiology recordings of DRG neurons, we found that 14 nociceptive neurons (C neurons) out of 17 neurons recorded from uninjured L4 DRG in 17 rats developed SA within a few minutes after L5 SNT, and remained active for at least 30 min (Fig.…”

“…Denervation from axotomy causes a loss of peripheral sensory inputs. Yet, pain can develop rapidly after nerve injury in patients 1–4 . Neuropathic pain-related manifestations, such as spontaneous pain and tactile and heat hypersensitivity, are also observed in animal models of nerve injury and may last for weeks.…”

Infusion Methods for Continuous Interscalene Brachial Plexus Block for Postoperative Pain Control after Arthroscopic Rotator Cuff Repair

“…A large amount and prolonged injection of bupivacaine resulted in myopathy in a clinical situation with ISBPB, and myotoxic effects should be a concern if ropivacaine is administered for long periods, though the concern is less than for bupivacaine [ 16 17 ]. Intraneural injection of local anesthetics during ISBPB may cause severe plexopathy and neurologic deficits [ 18 ]. In the current study, we did not encounter the problem of migration of the perineural catheter in any patients, but this could happen during the postoperative analgesic period [ 19 ].…”

Risk factors for occurrence of failed interscalene brachial plexus blocks for shoulder arthroscopy using 20 mL 0.5% ropivacaine: a randomised trial

“…The introduction of ultrasound visualisation has revolutionised regional anaesthesia (RA) due to the possibility of observing the end of the needle and visualising the spread of local anaesthetic (LA) on the monitor. Moreover, it allows one to reduce the dose of LA [1], shortens the time of the onset of RA [2], minimises the rate of failed blocks [3] and the occurrence of brachial plexopathy [4], as well as the frequency of other unwelcome adverse events, such as intravascular injections of cardio-or neurotoxic LA [5], and diaphragm paralysis [6,7] with respiratory disorder [8]. In the end, IPBP produces appropriate analgesia for the postoperative period compared with general anaesthesia, which improves patients' satisfaction [9,10].…”