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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
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