Anesth Analg 2006;102:650-651
© 2006 International Anesthesia Research Society
doi: 10.1213/01.ANE.0000190757.95843.75
LETTER TO THE EDITOR
Was the Postoperative Nerve Injury Really Related to the Performance of the Block?
Jacques E. Chelly, MD, PhD, MBA, and
Nader F.H. Adelmassieh, MD
Department of Anesthesiology, UPMC Shadyside, Pittsburgh, PA, chelje{at}anes.upmc.edu (Chelly)
Department of Physical Medicine and Rehabilitation, UPMC McKeesport Hospital, McKeesport, PA (Adelmassieh)
To the Editor:
Shah et al. presented an interesting case of a nerve injury supposedly evocative of an intraneural injection based on a) increased pressure on injection and b) electromyographic findings (1). The difficulty encountered at the time of injection might have been related to an occlusion of the bevel by the lesser trochanter. More importantly, the electromyographic study can only localize a lesion at, or proximal to, the most proximal abnormal muscle sampled (2). Therefore, this technique rarely helps to determine the site of a nerve injury. The electromyographic details reported in this case were more indicative of an injury anywhere at or above the level of the take off of the nerve branch to the anterior tibialis. There is experimental evidence that the intraneural injection of local anesthetic leads to irreversible nerve damage (3-5), but the model used remains artificial and far from any clinical situation. In contrast, the orthopedic literature clearly recognizes that nerve injury after lower extremity surgery frequently occurs at the level of the common peroneal nerve (6), regardless of the fact that a nerve block has been performed. Risk factors for these injuries include trauma (which was the case with this patient), preoperative valgus, stretching of the nerve during the perioperative period, prolonged tourniquet time, and compressive hematoma (7).
Anesthesiologists should recognize that surgical causes are more frequently the cause of a postoperative nerve injury than a nerve block and that clinical evidence of intraneural injection mediated nerve injury remains to be established.
References
- Shah S, Hadzic A, Vloka J, et al. Neurologic complication after anterior sciatic nerve block. Anesth Analg 2005;100:1515-7.[Abstract/Free Full Text]
- Preston DC, Shapiro BE. Electromyography and neuromuscular disorders: clinical-electrophysiologic correlations, 1st ed. Boston: Butterworth-Heinemann, 1998.
- Selander D, Sjostrand J. Longitudinal spread of intraneurally injected local anesthetics: an experimental study of the initial neural distribution following intraneural injections. Acta Anaesthesiol Scand 1978;22:622-34.[Web of Science][Medline]
- Gentili F, Hudson A, Kline D, Hunter D. Peripheral nerve injection injury: an experimental study. Neurosurgery 1979;4:244-53.[Medline]
- Middleton R, Varian J. Tourniquet paralysis. Aust N Z J Surg 1974;44:124-8.[Web of Science][Medline]
- Idusuyi OB, Morrey BF. Peroneal nerve palsy after total knee arthroplasty: assessment of predisposing and prognostic factors. J Bone Joint Surg Am 1996;78:177-84.[Abstract/Free Full Text]
- Ben-David B, Joshi R, Chelly JE. Sciatic nerve palsy after total hip arthroplasty in a patient receiving continuous lumbar plexus block. Anesth Analg 2003;97:1180-2.[Abstract/Free Full Text]
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